How Doctors Think and Learn [1st ed.] 9783030462789, 9783030462796

Table of contents :
Front Matter ....Pages i-xvii
Front Matter ....Pages 1-1
Professions (Derek Burke)....Pages 3-4
Knowledge (Derek Burke)....Pages 5-14
Learning (Derek Burke)....Pages 15-27
Experiential Learning Theory (Derek Burke)....Pages 29-37
Brain Plasticity, Learning and Memory (Derek Burke)....Pages 39-42
Constructivism and Objectivism (Derek Burke)....Pages 43-48
Skill (Derek Burke)....Pages 49-60
Competence (Derek Burke)....Pages 61-63
Assessment and Appraisal (Derek Burke)....Pages 65-74
Tacit Knowledge (Derek Burke)....Pages 75-80
Theories of Action (Derek Burke)....Pages 81-88
Reflection (Derek Burke)....Pages 89-95
Front Matter ....Pages 97-97
Overview to Synthesis (Derek Burke)....Pages 99-106
Tacit Knowledge Revisited (Derek Burke)....Pages 107-119
Skill, Competence and Assessment Revisited (Derek Burke)....Pages 121-135
Theories of Action and Transforming Thought into Action Revisited (Derek Burke)....Pages 137-142
Reflection Revisited (Derek Burke)....Pages 143-154
Front Matter ....Pages 157-157
Conceptual Framework (Derek Burke)....Pages 157-175
Back Matter ....Pages 177-186

Citation preview

How Doctors Think and Learn Derek Burke

123

How Doctors Think and Learn

Derek Burke

How Doctors Think and Learn

Derek Burke Head of Clinical Governance and General Medical Council Suitable Person Gibraltar Health Authority St Bernard’s Hospital Gibraltar Gibraltar

ISBN 978-3-030-46278-9    ISBN 978-3-030-46279-6 (eBook) https://doi.org/10.1007/978-3-030-46279-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my mother and father who taught me the value of learning To my wife who, with good humour year on year, accepted my assurance that it was “nearly there”.

Preface

When I graduated from medical school in 1983, medicine was a science based craft acquired through apprenticeship. There was no formal system of competency-based training or assessment. Skills were acquired on the basis of “see one, do one, teach one”. At the end of higher specialist training, a system of accreditation determined successful completion of training. There was no system of appraisal or annual review. Since then, medical training has become highly structured and comprehensively assessed. Achieving competence is now seen as the measure of medical attainment. But competence was not a term which would have been in general use in medical practice in 1983. The graph below shows a plot of Medline citations for the term "clinical competence” for the period 1980–2018 (the last full year of citations available). From reviewing that graph and from my own personal experience of training and practising in that period, I have set the start date for competency-based medical practice in the UK as 1990. Clinical Competence Citations Medline 1980-2018 7000 6000 5000 4000 3000 2000 1000 0 2018 2016 2014 2012 2010 2008 2006 2004 2002 2000 1998 1996 1994 1992 1990 1988 1986 1984 1982 1980 Competence

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Additional supporting evidence for that date is that it coincides with the introduction of structured resuscitation courses into the UK.  The American Heart Association Advanced Cardiac Life Support Course was introduced in the USA in 1975 and in the UK in 1985 (the Resuscitation Council Course was first run in 1991/93). The American College of Surgeons Advanced Trauma Life Support Course was first introduced in the USA in 1978 and in the UK in 1988. Paediatric resucitation courses were introduced into the UK in 1990. At first, these courses were few and far between and it took a number of years for a significantly large number of doctors to attend at least one course. These courses were the earliest structured approach to competency-based training and assessment in the UK where the possibility of failure existed. They led, slowly, to a whole generation of doctors acquiring the skills to teach in a structured manner and to assess successful acquisition of those skills to an agreed level of competence. Over the past 30-years competency-based training and assessment has progressed to encompass the whole of undergraduate and postgraduate medical education and training. This development coincided with a reduction in working hours from a basic 83 hours per week to a basic 48 hours per week and a reduction in years of training from graduation to consultant appointment from about 14 years to about 10 years. It would not be going too far to propose that the reduction in the hours and years of training required to attain the skills to practise as a consultant would not have been possible without the development of structured competency-based training and assessment programmes. We may consider the period 1990–2020 as the “age” of competency-based practice in UK Medical practice. We have made great strides in standardising the outputs of medical training schemes over that period, but what of higher levels of attainment beyond competence? Dreyfus and Dreyfus describe a five-stage model of skill acquisition: Novice, Advanced Beginner, Competent, Proficient and Expert. The Novice/Advance Beginner stages are typified by those in the clinical stages of undergraduate training to the earlier years of postgraduate training. The competent stage typifies those in the later stages of postgraduate training. The proficient  stage is only attained by senior practitioners with many years of experience. As not all practitioners attain the expert stage I will not consider that stage further. The graph below shows a plot of Medline citations for the period 1980–2018 for the terms “clinical competence” and “clinical proficiency”. We can see that citations for the term “clinical proficiency” made up only 3% of citations in 1980 and rose to only 10% of citations in 2018.

Preface

ix Clinical Competence and Clinical Proficiency Citations Medline 1980-2018

7000 6000 5000 4000 3000 2000 1000 0 2018 2016 2014 2012 2010 2008 2006 2004 2002 2000 1998 1996 1994 1992 1990 1988 1986 1984 1982 1980

Proficiency

Competence

I would propose that just as a structured approach to the delivery and assessment of competency-based practice has facilitated shorter training periods while maintaining standards, then a structured approach to the delivery and assessment of proficiency-­based practice should reduce the time to achieving a proficient level of performance. The problem we face is that the thought processes underpinning proficient practice are qualitatively different to those required for competency-based practice. We cannot simply translate the techniques which have given success in competency-based training to training in proficiency. Having trained under the craft-based system and been a trainer of doctors and nurses, both undergraduate and postgraduate during the age of competence I came to realise that although I knew how to teach, I had very little notion of how students became fully fledged professionals as a result of that teaching. I reasoned that if we were to develop successful techniques for training doctors to be proficient, then we had to understand how doctors learn to be doctors. This is akin to the development of new treatments. The more we understand the pathophysiology of the underlying condition we want to treat, the more likely we are to develop new and successful treatments. Trial and error may eventually give us the result we want, but that process is likely to take a lot longer than a rational knowledge-based approach. This book is the result of that work. It took nearly 13 years to write rather than the six months I had originally planned it to take. If left to my own devices, it would take another 13 years. However, there comes a time when you have to drop the pen and expose your thoughts to the wider world for good or bad.

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This book is split into three parts. Part I considers the elements underpinning thinking, learning and professional practice by reviewing the available literature. Part II provides a synthesis of the information from Part I and adds my thoughts and perspectives. Part III presents a conceptual framework for how doctors acquire, develop and refine their knowledge and skills based on the elements in Parts I and II. Because of the interdependance of the parts I would recommend reading them, at least on first reading, in the order as presented. The book is deliberately written in non-technical language to make it available to the widest possible audience. I suggest that it would interest anyone who is involved in professional education or training The model is generic and covers the development of professionals rather than just healthcare professionals. Because of my backgound in medicine I have used clinical examples, but other than that the framework would be equally applicable to lawyers and accountants as it is to doctors or nurses. It is my hope that this book will contribute to work on the development of a structured approach to training postgraduate practitioners in proficiency-based practice and that the next 30 years will come to be seen as the age of proficiencybased medical practice in the UK just as the last 30 years were the age of competency-based medical practice. May 2020

Derek Burke Gibraltar

Acknowledgements

I would like to thank my colleagues Dr Alison Smith and Professor Prasad Godbole for reviewing earlier drafts of this book and Professor Amaka Offiah and Dr John Tripp for reviewing the final draft. Their input significantly improved the readability of the book. A special mention to Dr Tom Beattie for not only reviewing the book but also for kindly inviting me to be external examiner for the Edinburgh University MSc in Paediatric Emergency Medicine. The 6 years I undertook this role provided invaluable insights into the cognitive development of postgraduate doctors and crystallised my thoughts on Bloom’s taxonomy of the cognitive domain, Anderson and Krathwohl’s revision of Bloom’s taxonomy and also Krathwohl’s taxonomy of the affective domain. Particular thanks to Dr Daniel Cassaglia, consultant paediatrician, medical director and chief executive of the Gibraltar Health Authority for inviting me to give a talk on tacit knowledge to the Paediatric Visiting Club meeting in Gibraltar in September 2018. The preparation for that talk and the discussion with that group in the following two days enhanced my understanding and conceptualisation of the nature of tacit knowledge and led to the development of the model of the structure of knowledge used in the book. Thanks also to Dr Ruth Brown and Dr Jacky Hanson with whom I was involved in some of the early work on revalidation for the College of Emergency Medicine. This experience helped formulate my thoughts on reflection and skill acquisition and my early thoughts on skill sets. My understanding of the structure of skill sets and complex skill sets was greatly enhanced by a very useful discussion with Dr Rachel Tattersall. Dr Alistair Pickering suggested the term abstention in relation to the application of Piaget’s schemas to postgraduate trainees. Thanks also to Dr Pete Driscoll. I first met Pete in about 1988 when I was a senior house officer and he was senior registrar in the Accident and Emergency Department at Whipps Cross hospital. Our paths crossed a number of times in the intervening years in particular when examining in the College  of Emergency Medicine Objective Structured Clinical Examinations when Pete was the Dean of the College. Even in the 1980s, Pete was an inspiration to those who had an interest in medical education, and he continues to inspire a new generation of practitioners

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in his new role as Academic Lead for the Physician Associate Programme at the School of Medicine, University of Central Lancashire. Finally, my thanks to John Schostak, Jill Schostak and Tony Brown of Manchester Metropolitan University for opening my eyes to the wider literature on education and to Jill for asking the question “how do doctors make a diagnosis?” which triggered some of the earlier thoughts which led to this book. I hope this book goes some way to answering that question. June 2020

Derek Burke St Bernard’s Hospital Gibraltar

Contents

Part I Literature Review 1 Professions��������������������������������������������������������������������������������������������������   3 Summary����������������������������������������������������������������������������������������������������    4 References��������������������������������������������������������������������������������������������������    4 2 Knowledge��������������������������������������������������������������������������������������������������   5 Belief����������������������������������������������������������������������������������������������������������    5 Truth����������������������������������������������������������������������������������������������������������    6 Empiricism and Rationalism����������������������������������������������������������������������    7 Justification������������������������������������������������������������������������������������������������    9 Reason and Rational Thinking������������������������������������������������������������������   10 Logic����������������������������������������������������������������������������������������������������������   11 Summary����������������������������������������������������������������������������������������������������   12 The Two Sorts of Knowledge��������������������������������������������������������������������   12 Summary����������������������������������������������������������������������������������������������������   13 References��������������������������������������������������������������������������������������������������   13 3 Learning������������������������������������������������������������������������������������������������������  15 The Three Domains of Learning����������������������������������������������������������������   15 Cognitive Domain��������������������������������������������������������������������������������������   15 Knowledge Domain ����������������������������������������������������������������������������������   16 Intellectual Abilities and Skills Domain����������������������������������������������������   17 Anderson and Krathwohl’s Modification of Bloom’s Taxonomy��������������   18 Affective Domain��������������������������������������������������������������������������������������   25 Psychomotor Domain��������������������������������������������������������������������������������   25 Summary����������������������������������������������������������������������������������������������������   26 References��������������������������������������������������������������������������������������������������   26 4 Experiential Learning Theory������������������������������������������������������������������  29 Learning Style Inventory����������������������������������������������������������������������������   33 First-Order Learning Strategy��������������������������������������������������������������������   33 Second-Order Learning Strategy ��������������������������������������������������������������   34 Third-Order Learning Strategy������������������������������������������������������������������   34 Nine Learning Styles and Four Dialectic Tensions������������������������������������   34

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Learning Flexibility ����������������������������������������������������������������������������������   35 Summary����������������������������������������������������������������������������������������������������   36 References��������������������������������������������������������������������������������������������������   37 5 Brain Plasticity, Learning and Memory��������������������������������������������������  39 Learning ����������������������������������������������������������������������������������������������������   39 Memory������������������������������������������������������������������������������������������������������   40 Summary����������������������������������������������������������������������������������������������������   41 References��������������������������������������������������������������������������������������������������   42 6 Constructivism and Objectivism��������������������������������������������������������������  43 Objectivism and Constructivism����������������������������������������������������������������   43 Constructivism, Cognitive Constructivism, Social Constructivism����������   44 Lev Vygotsky (1896–1934) ����������������������������������������������������������������������   44 The Zone of Proximal Development (ZPD)����������������������������������������������   44 More Capable Peer������������������������������������������������������������������������������������   44 Jerome Bruner (1915–2016)����������������������������������������������������������������������   45 Jean Piaget (1896–1980)����������������������������������������������������������������������������   45 Schema������������������������������������������������������������������������������������������������������   45 Piaget’s Schemas������������������������������������������������������������������������������������   45 Assimilation: “Fit Practice to Theory”������������������������������������������������������   45 Accommodation: “Fit Theory to Practice”������������������������������������������������   46 Adaptation��������������������������������������������������������������������������������������������������   46 Jonassen’s General Characteristics of Constructivist Learning Environments ��������������������������������������������������������������������������������������������   46 Eraut’s Routinisations��������������������������������������������������������������������������������   47 A Word About Aptitude ����������������������������������������������������������������������������   47 Summary����������������������������������������������������������������������������������������������������   48 References��������������������������������������������������������������������������������������������������   48 7 Skill��������������������������������������������������������������������������������������������������������������  49 Novice��������������������������������������������������������������������������������������������������������   51 Advanced Beginner������������������������������������������������������������������������������������   51 Competence������������������������������������������������������������������������������������������������   52 Proficiency ������������������������������������������������������������������������������������������������   53 Expertise����������������������������������������������������������������������������������������������������   55 Two Additional Stages ������������������������������������������������������������������������������   55 Mastery and Practical Wisdom��������������������������������������������������������������   55 The Role of the Teacher in Skill Acquisition��������������������������������������������   56 Progression of the Components of the Dreyfus and Dreyfus Model ��������   56 Summary����������������������������������������������������������������������������������������������������   58 References��������������������������������������������������������������������������������������������������   58 8 Competence������������������������������������������������������������������������������������������������  61 Summary����������������������������������������������������������������������������������������������������   62 References��������������������������������������������������������������������������������������������������   62 9 Assessment and Appraisal ������������������������������������������������������������������������  65 Types of Assessment����������������������������������������������������������������������������������   65

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What Should Be Assessed?������������������������������������������������������������������������   66 The Requirements of a Good Assessment Test������������������������������������������   66 Norm, Criterion-Referenced and Ipsative Assessment������������������������������   66 Types of Assessment����������������������������������������������������������������������������������   67 The Blueprint ��������������������������������������������������������������������������������������������   67 Defensible Assessment������������������������������������������������������������������������������   67 Miller’s Framework������������������������������������������������������������������������������������   68 Enhanced Appraisal ����������������������������������������������������������������������������������   69 Summary����������������������������������������������������������������������������������������������������   72 References��������������������������������������������������������������������������������������������������   72 10 Tacit Knowledge ����������������������������������������������������������������������������������������  75 Polanyi’s Model of Tacit Knowledge��������������������������������������������������������   75 Collins’ Taxonomy of Tacit Knowledge����������������������������������������������������   77 Summary����������������������������������������������������������������������������������������������������   79 References��������������������������������������������������������������������������������������������������   80 11 Theories of Action��������������������������������������������������������������������������������������  81 The Structure of Theories-in-Use��������������������������������������������������������������   82 Governing Variables������������������������������������������������������������������������������   82 Action Strategies������������������������������������������������������������������������������������   83 Consequences����������������������������������������������������������������������������������������   83 Theories-in-Use������������������������������������������������������������������������������������������   83 Dilemmas ��������������������������������������������������������������������������������������������������   84 Single- and Double-Loop Learning ����������������������������������������������������������   84 Model I and Model II Behaviour ��������������������������������������������������������������   84 Characteristics of Model I Behaviour����������������������������������������������������   85 Characterisitics of Model II Behaviour��������������������������������������������������   86 Surmmary��������������������������������������������������������������������������������������������������   86 References��������������������������������������������������������������������������������������������������   87 12 Reflection����������������������������������������������������������������������������������������������������  89 Reflection-in-Action����������������������������������������������������������������������������������   89 Reflection on Action����������������������������������������������������������������������������������   90 Framing������������������������������������������������������������������������������������������������������   90 Gibbs (1988) Model of Reflection ������������������������������������������������������������   92 John’s Model of Reflection������������������������������������������������������������������������   93 A Third Model of Reflection����������������������������������������������������������������������   94 Summary����������������������������������������������������������������������������������������������������   94 References��������������������������������������������������������������������������������������������������   95 Part II Synthesis 13 Overview to Synthesis��������������������������������������������������������������������������������  99 Ontology and Epistemology����������������������������������������������������������������������   99 Hierarchy of Comprehensive Entities��������������������������������������������������������  100 Positivism��������������������������������������������������������������������������������������������������  102 Dualism������������������������������������������������������������������������������������������������������  103

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Gestalt Psychology������������������������������������������������������������������������������������  103 The Hermeneutic Cycle ����������������������������������������������������������������������������  104 Conceptual Framework������������������������������������������������������������������������������  104 Simple, Complicated and Complex [13]����������������������������������������������������  105 References��������������������������������������������������������������������������������������������������  105 14 Tacit Knowledge Revisited������������������������������������������������������������������������ 107 Cognitive Perspective on Tacit Knowledge ����������������������������������������������  108 The Knowledge Dimension ����������������������������������������������������������������������  109 The Source Dimension������������������������������������������������������������������������������  112 The Utility or Action Dimension ��������������������������������������������������������������  113 Hardwiring and Tacit and Explicit Knowledge������������������������������������������  115 A Note on Tacit Knowing and Tacit Knowledge ��������������������������������������  118 Summary����������������������������������������������������������������������������������������������������  118 Reference ��������������������������������������������������������������������������������������������������  119 15 Skill, Competence and Assessment Revisited������������������������������������������ 121 Skill������������������������������������������������������������������������������������������������������������  121 Skill Set������������������������������������������������������������������������������������������������������  122 Piaget’s Schema’s Revisited����������������������������������������������������������������������  124 Cognitive Basis for Skill Acquisition��������������������������������������������������������  126 Memory��������������������������������������������������������������������������������������������������  126 Psychomotor Skill Acquisition������������������������������������������������������������������  128 Competence������������������������������������������������������������������������������������������������  129 Assessment������������������������������������������������������������������������������������������������  132 Summary����������������������������������������������������������������������������������������������������  134 Reference ��������������������������������������������������������������������������������������������������  135 16 Theories of Action and Transforming Thought into Action Revisited ���������������������������������������������������������������������������������������� 137 The Origin of the Driver(s) to Act ������������������������������������������������������������  137 Maslow’s Hierarchy of Needs��������������������������������������������������������������������  138 Herzberg’s Hygiene and Motivational Factors������������������������������������������  139 Modified Structure of Theory of Action����������������������������������������������������  140 How the Driver to Act Is Transformed into Action?����������������������������������  140 Summary����������������������������������������������������������������������������������������������������  141 References��������������������������������������������������������������������������������������������������  142 17 Reflection Revisited ���������������������������������������������������������������������������������� 143 What we reflect on ������������������������������������������������������������������������������������  143 Reflect on Your Actions, the Outcome of Those Actions and the Plan Which Defined Those Actions ����������������������������������������������������  145 Reflection on Your Perspective of the Situation You Are in, the Elements That Perspective Specifies and the Goal Which Defined That Perspective ��������������������������������������������������������������������������  149 Reflect on Your Governing Variables and the Needs and Beliefs That Underlie Those Governing Variables������������������������������������������������  150

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Reflection on Your Contingent Variables, the Origins of Your Contingent Variables and How They Enhance or Inhibit Your Governing Variables����������������������������������������������������������������������������������  152 Reflect on Your Theories in Use, Your Espoused Theories, the Behavioural Worlds They Create and the Congruence Between Them ������������������������������������������������������������������������������������������  152 Summary����������������������������������������������������������������������������������������������������  153 Further Reading ����������������������������������������������������������������������������������������  154 Part III Conceptual Framework 18 Conceptual Framework���������������������������������������������������������������������������� 157 Novice Student������������������������������������������������������������������������������������������  158 Advanced Beginner Student����������������������������������������������������������������������  161 Competent Practitioner������������������������������������������������������������������������������  165 Expert Practitioner ������������������������������������������������������������������������������������  172 Summary����������������������������������������������������������������������������������������������������  175 References��������������������������������������������������������������������������������������������������  175  Appendix: The Diligent Librarian Model for the Structure of Knowledge������������������������������������������������������������������������������ 177 Index�������������������������������������������������������������������������������������������������������������������� 183

Part I Literature Review

1

Professions

Before embarking on the main subject of the book, it is helpful to have some understanding of the nature of professional practice. Professional practice involves the solving of specific problems by applying general principles [1]. There are two elements to professional practice; the area of knowledge to which the professional lays claim and the method(s) of producing and applying that knowledge [2]. There are three components of professional knowledge: [3]. • A basic science component that forms the foundation of professional practice. • An applied science component from which the diagnostic and problem-solving processes characteristic of a specific profession are developed. • A skills and attitudinal component which underpins the delivery of the professional service to the user. Schőn notes this hierarchy with the service deliver component (i.e. the problem-­ solving elements of professional practice) being derived from the applied science component and the applied science component being derived from the basic science component. He further notes that higher status is afforded to those who produce the more basic levels of knowledge than those who produce the higher levels [4]. The traditional curricula of professional schools follow the ordering of derivation of these three components. The basic sciences are taught first followed by the applied sciences. Attitudinal and skills components are delivered either with the applied sciences or later in the curriculum. The timing of delivery of the skills and attitudinal component depends on how easily service users can be accessed or on the practicality of realistically simulating the professional encounter [5]. The medical curriculum is the prototypical example. The traditional undergraduate medical curriculum is divided into two stages: preclinical and clinical. The basic sciences and the early phase of the applied sciences are delivered in the preclinical

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_1

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1 Professions

stage within the academic setting of the lecture theatre, seminar room or laboratory. The later phase of the applied sciences and training in the clinical skills, which incorporates the skills and attitudinal components, are delivered on the wards and in the outpatient departments [6].

Summary In summary, professional practice is defined in terms of the production (research), distribution (teaching and training) and application (clinical practice) of a defined body of specialised knowledge. If knowledge is central to professional practice, then in order to understand how we learn as professionals we need to understand something of the nature of knowledge and how it is acquired. We will consider this in the next chapter.

References 1. 2. 3. 4.

Moore W. The professions. New York: Russell Sage Foundation; 1970. p. 56. Ibid. p. 141. Schein E. Professional education. New York: McGraw-Hill; 1973. p. 43. Schőn D.  The reflective practitioner: how professionals think in action. New  York: Basic Books; 1983. p. 24. 5. Schein E. Professional education. New York: McGraw-Hill; 1973. p. 44. 6. Gartner A. Preparation of human services professionals. New York: Human Sciences Press; 1976. p. 80.

2

Knowledge

Knowledge is a justified true belief. [1]

To fully understand this formal definition ascribed to Plato, we must break it down into its component parts.

Belief A belief is a view we have about reality. Some of our beliefs are great statements of conviction, but most beliefs relate to the more routine aspects of daily living. Beliefs have two components: the objective component, that which we believe in and the subjective component, how strongly we hold that belief [2]. Some Beliefs • • • • • • • •

A is the first letter of the alphabet. I am a British citizen. The Allies won the Second World War. Santa Claus lives at the North Pole. An orange is a fruit. Rain is wet. All men are equal. Breaking the speed limit is wrong.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_2

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2 Knowledge

We each have a vast number of beliefs which constitute our internal map of reality. That is why it is important that we know that our beliefs are true reflections of that reality [3]. Reality

If we took all human life out of the Universe, we would be left with reality. Reality “is what is” and exists independent of conscious thought. Beliefs may be true or false. We all hold many false beliefs which we believe to be true [4]. Such beliefs do not constitute knowledge. To constitute knowledge, the belief must be true [5]. A False Belief

I believed this morning when I left home that I had my wallet with me, I was embarrassed to find, when trying to pay for some goods in a shop, that I had left my wallet at home.

A True Belief

I believe that London is the capital city of England.

Truth Aristotle said of truth: “To say of what is that it is not, or of what is not that it is, is false; while to say of what is that it is, and of what is not that it is not, is true”. [6]

There are two broad views about how we derive true beliefs: empiricism and rationalism.

Empiricism and Rationalism

7

Empiricism and Rationalism Empiricists believe that our knowledge is derived from our senses [7]. Rationalists believe that much of our knowledge is either self-evidently true and requires no additional sense experience to validate its truth, or it is derived by the application of reason [8], e.g. the axioms of arithmetic. The Axioms* of Arithmetic [9, 10]

For all real numbers m, n: • m + n = n + m • mn = nm

For all real numbers m, n, k: • (m + n) + k = m + (n + k) • (mn)k = m(nk)

For all real numbers m, n, k: • k(m + n) = km +kn • m(n + k) = mn + mk • n(m + k) = nm + nk

There is a real number 0 where for any real number n: • n + 0 = n

There is a real number 1 where for any real number n: • n x 1 = n

8

2 Knowledge

For every real number n, there is a real number k where: • n + k = 0

For any real number m, n, k: • If k ≠ 0 and kn = km, then m = n

None of these axioms has been proven to be true, yet they form the foundations of the whole system of arithmetic. That airplanes fly, economic systems function and computers work, all based on the system of arithmetic derived from these seven axioms, provides strong supporting evidence for their validity.

* an axiom is a fundamental proposition that is taken to be self-­evidently true In reality, we use a combination of empiricism and rationalism to construct our belief system. Ontology and Epistemology

“What is the nature of existence and how can we come to know it?”

Two major branches of philosophy deal with the nature of existence or reality (ontology) and the nature of knowledge (epistemology). We can summarise the relationship between the two branches as ontology posing the question, “What is the nature of existence or reality?” and epistemology posing the question, “How we can know?”

Justification

9

Justification Holding a belief that is true, but not definitely knowing that it is true does not constitute knowledge. To constitute knowledge, we must have some grounds for holding that our belief is true (That is the truth must be justified). In addition, the grounds must be of the right sort (That is the justification must be of the proper sort) [11]. In the arithmetical example above the fact that there are millions of confirmations of the axioms of arithmetic on a daily basis worldwide does not constitute proper justification for a mathematician to believe that they are true. It may be that we have just not found the marginal case where they do not apply. Proper Justification

Example 1

“I believe that under the icy surface of Europa (one of the moons of Jupiter) there is a sea containing life".

It may be that this belief is true (That is it has a basis in reality), but I have no evidence to support this view other than my belief that it is true. Mere luck or coincidence between my beliefs and reality does not constitute knowledge. There must be an appropriate connection between my true belief and reality in order that my true belief constitutes knowledge [12].

If 99% of the population of the world believed that under the icy surface of Europa there is a sea containing life, this would not constitute proper justification as scientific facts are not established on the basis of consensus view.

If an interplanetary probe landed on Europa and discovers a sea beneath the icy surface containing life, then this true belief is justified as it meets the criteria for scientific knowledge.

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2 Knowledge

Example 2

“I believe that my MP is the legitimate elected MP for my constituency as they received the largest share of the vote”.

Under the current UK electoral system, the candidate who has the largest share of the vote (not necessarily the majority (> 50%) of the vote) is elected MP.

This is a true belief which is justified as the evidence put forward (the total number of votes cast and the total number my MP received) shows that they met the criteria for election. My belief therefore constitutes knowledge. The concept of “justified” is not fixed, but it depends on the type of belief we are considering. Compare the two examples in the box above where justification in the first is defined in terms of direct observation and the second in meeting an agreed or established criterion. The justification for the belief that a particular fact of physiology is true and therefore constitutes knowledge depends on who you are. For a cutting-­ edge academic physiologist, we may set the criteria that the fact has been published in an appropriate peer-reviewed journal which subjects it to challenge by the community of physiologists. For a medical student, the criteria may be that the fact is published in a current standard textbook of physiology. How do we know when justification is proper?

Reason and Rational Thinking Reason is our ability to impose order and meaning on the data derived from our sense organs, so that we may develop an accurate model of the real world [13]. The application of reason to that data is called rational thinking. A rational belief is a belief derived from the application of reason. Rational beliefs keep us aligned with the truth: truth keeps us aligned with reality. When we refer to proper justification we are speaking of justification derived from the application of reason [14]. We can consider the analogy of a computer to help us understand the nature of reason. A computer comprises a central processing unit (CPU) at the core of which binary signals from peripheral devices (e.g. keyboard, mouse and camera) are

Logic

11

processed. The binary signals from different peripherals require processing in different ways in order that sense can be made of the data. A programme is a series of instructions which tell the CPU how to process the incoming signals to produce the correct interpretation (information), e.g. Data input: OOXOOOXXXOXXXXXOXXXOOOXOO Programme: press return key after every five bits of data: OOXOO OXXXO XXXXX OXXXO OOXOO Our brain can be considered to be analogous to the CPU of a computer. It is a generic processor that works on binary input (in the case of our brain a neuron either has or does not have an action potential flowing). Sensory inputs to the brain are derived from a number of different sense receptors or organs each of which responds to different types of stimulus (e.g. light, sound and temperature), the sensory outputs of the sensory receptors or organs will be a binary sequence (action potential or no action potential) irrespective of the type of sensor. The brain has to be told how to interpret the sensory output from each receptor or organ type to derive the right information to make sense of the world. Reason is the general term used to describe the “programmes” which tell our brain how to interpret the data derived from our sense organs. If we apply the appropriate programme (reason) to the incoming data, we will produce the correct (rational) interpretation (information) which should ensure that our interpretation of the data aligns with reality (That is it is true and therefore constitutes knowledge).

Logic Logic is a specific type of reason which uses a formal system of argument (the laws of logic) which, when applied to a true belief (whether it is derived empirically or rationally), enables us to derive further true beliefs. As long as we are certain that we are starting with a true belief and we correctly apply the laws of logic we can be certain that we are extrapolating from known truths to previously unknown truths [15]. Nuclear submarines stay submerged and undetected for prolonged periods. They navigate without any external reference points to tell them where they are by using an inertial navigation system. This comprises movement sensors (accelerometers) and rotation sensors (gyroscopes) which continually feed changes in direction of travel and velocity to a computer. If the computer is programmed with the precise starting position of the submarine, it can use the data from the inertial navigation system to calculate the current position.

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2 Knowledge Congruence = Truth Empiricism

Reality

Phenomenon

Brain

Body

Sense Organ

Reason

Knowledge 1

Rationalism (Logic)

Truth

Knowledge 2

Fig. 2.1  Diagram of the pathway for the processing of data to produce knowledge

In an analogous way the laws of logic allow us, if we start from a known truth, to navigate to new truths.

Logic may be thought of as the inertial navigation system of our reason.

Summary In summary (see Fig. 2.1), our sense organs provide us with empirical data about the world we live in. This data has to be interpreted by our brain using reason which, if correctly applied, provides us with information which gives us a true picture of the world we live in. We can also derive information about the world by re-processing empirically derived information using our reason (rationalism/logic) to generate theories or hypotheses about the world which we can test by comparing predictions derived from them with the real data derived from our sense organs.

The Two Sorts of Knowledge Oakeshott described two sorts of knowledge. The first sort of knowledge he called technical knowledge. Technical knowledge can be described in terms of rules which can be committed to memory and turned into actions. Oakeshott gave as examples of technical knowledge the components of driving described in the Highway Code or the method of cooking described in a cookery book [16]. The second sort of knowledge he called practical knowledge, because it can only exist in use and cannot be expressed as rules. An example of practical knowledge is

References

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the ability of a fielder in cricket to judge how hard to throw a ball so that it knocks the bails off the stumps [17]. Oakeshott noted that: “These two sorts of knowledge, then, distinguishable but inseparable, are the twin components of knowledge involved in every concrete human activity”. [18]

Ryle [19] used the term “knowing that” to describe technical knowledge and “knowing how” to describe practical knowledge. Polanyi [20] coined the term “tacit knowing” which equates to practical knowledge (Oakeshott) and “knowing how” (Ryle). For our purposes, we will describe technical knowledge or “knowing that” as explicit knowledge and practical knowledge or “knowing how” as tacit knowledge. Explicit knowledge: The knowledge we are taught or learn. We read about it in textbooks, can articulate it and pass it directly on to others, they in turn, with the right skills, can reproduce it (That is it is codifiable, transmissible and reproducible). It is defined in curricula and tested in assessments; it is the spoken and written knowledge of our everyday life. Tacit knowledge: The knowledge we acquire through experience. By working in a particular environment, we acquire the ability to “do it as it is done here”. An individual knows they have tacit knowledge by virtue of their ability to do a job or perform a particular task. But they may find it difficult to articulate that tacit knowledge or pass it directly on to others. If asked how they “do it” they may respond “it is difficult to describe” or “just watch how I do it”. We will discuss the types and structure of tacit and explicit knowledge in later sections. When we use the term “knowledge” throughout the remaining chapters we will, in the main, be referring to the generic use of the term knowledge as “beliefs” or more broadly to include the knowledge required to execute a skill rather than the more formal definition ascribed to Plato.

Summary In summary knowledge is a properly justified true belief. For a belief to be deemed true there must be evidence linking that belief to reality, in addition that evidence must be of the correct type. Knowledge can be derived from sense experience (empirical) or by the application of reason (rational). Knowledge is either explicit or tacit. In the next chapter, we will consider the nature of learning and the structure of explicit knowledge.

References 1. Morris T. Philosophy for dummies. New York: Wiley; 1999. p. 45. 2. Ibid. p. 42.

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2 Knowledge

3. Ibid. p. 41. 4. Ibid. p. 43. 5. Ibid. p. 45. 6. Ibid. p. 46. 7. Ibid. p. 68. 8. Ibid. p. 69. 9. Singh S. Fermat’s last theorem. London: Fourth Estate Limited; 1997. p. 342–3. 10. https://www.jamesbrennan.org/algebra/numbers/properties_of_real_numbers1.htm (Accessed 25 04 2020) 11. Morris T. Philosophy for dummies. New York: Wiley; 1999. p. 48–9. 12. Ibid. p. 48. 13. Ibid. p. 31. 14. Ibid. p. 49–51. 15. Ibid. p. 51–52. 16. Oakeshott M.  Rationalism in politics: and other essays. Indianapolis: Liberty Fund; 1991, p. 12. (First published 1962: London, Methuen). 17. Ibid. 18. Ibid. 19. Ryle G.  On knowing how and knowing that. In The concept of mind. London: Hutchison; 1940, p. 32. 20. Polanyi M. The tacit dimension. London: Routledge; 1967. p. 9.

Bibliography Morris T. Philosophy for dummies. New York: Wiley; 1999. A useful overview of the nature of knowledge for the novice. Pritchard D. What is this thing called Knowledge? London and New York: Routledge; 2006. Pritchard provides a more in depth analysis of the nature of knowledge. https://plato.stanford.edu/entries/knowledge-analysis/ (Accessed 25/03/2020) A good on-line analysis of the nature of knowledge Ga. Nam, odiciis in peri consequ idebis reptassed molorepel il iliquaest eiur ratur soluptatum quationserae porepel luptur atur, ipsunt estium nonecero tem volestibus expliti to eaturiatum quatectet et quo optaerferunt ad quias inis dolut voluptibus dem aut voluptatur res et quam reperum is reperup tasperunt eiciis il intis rem volecab illautem rempernamet quam quas corem re ipic tem dem hiliquunt ad et explam, solupitaqui delicit ea voluptat qui doluptatet delendit exceped eum ad eaqui nonet quos est, to essum, tem. Nus evendis sit modit que sita nonseri busam, tem eaquodipsum eatur sitios et officiis sum harum quas dernati digent estrum re praeproria volent ventur as dolupidunt in re exces alia derum, et que volent pre pliberupta im evellor rovitatur, sitibusdam qui dolupta con nus, ad ut doluptatur atia voluptionem eati ut a ium quossitibea cuptae nis ape santem si alit alibusdam nem que volorempos dis aut ra quo volo blatur sitium quatque aut delendione perro explitiae simus eatur se nus, ium ipsuntent. Ebit, sum ium veliqui ut et peroribus. Roviden ihiciat aciuscilibus anis num inimusam quistium am, cum lic tem dolo tem quasinv elique que cus mos aborestor aut laborit vellaccum ius, odis doloribusa eatem verio doluptae. Nis aut evendendunt odi aut imilluptatis et voloreste pre porepero eum aute perum as doluptatus quiam venderumquid que dest qui del magniendi vendigenimil int pel in nitas accabore lit ulpa delecea tempos ma dolupti atestrumquis quia quam arit velenisit am acitia quianis dit optatusdae aut delenim ipic tes dentore rnatem rehendunt. Em rescius exerum nonestibus et explabor magnatum into conectus nos estibus daeperit, consequis ma ipsum si sectota accus et voluptinulpa quatam recat.

3

Learning

Learning is an activity which leads to a sustained change in behaviour.

The Three Domains of Learning When discussing learning, it is useful to start with the work of Benjamin Bloom. In 1948 at a meeting of college examiners, discussion took place about the difficulty in exchanging assessment tools (e.g. multiple-choice questions) because different examiners used slightly different definitions for the same terms. The development of a taxonomy to facilitate communication between examiners was agreed upon. At the most basic level, this would allow the interchange of exam questions with standardised meanings. A group was set up to progress the project [1, 2]. The group divided the work on the taxonomy into three domains: [4] • Cognitive (thinking): Problem solving • Affective (feeling): Engagement • Psychomotor (action): Physical manipulation [3] It was agreed that the basis for the taxonomy would be a classification of the goals of the educational process: educational objectives. Educational objectives define the specific behavioural changes expected of students from a particular learning experience.

Cognitive Domain Bloom’s taxonomy of the cognitive domain was published in 1956. The taxonomy was divided into two sections:

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_3

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3 Learning

Evaluation

Synthesis

Analysis

Application

Comprehension

Knowledge

Fig. 3.1  Bloom’s taxonomy of the cognitive domain

• Knowledge section: knowledge and the cognitive class remembering [5]. • Intellectual abilities and skills section containing all the other cognitive classes [6]. In relation to the separation of the knowledge section from the intellectual abilities and skills section Bloom noted that knowledge is involved in all of the categories of the taxonomy but the knowledge category differs in that remembering is the dominant process. In other categories, remembering is part of a more complex cognitive process.’ [7] The taxonomy is a hierarchical classification where the underlying organising principle of the cognitive domain is increasing complexity [8] and of the knowledge domain is progression from concrete to more abstract knowledge [9]. There are 6 classes in taxonomy (see Fig. 3.1); with 21 sub-classes. The 6 classes and 21 sub-classes of Bloom’s taxonomy of the cognitive domain: [10]

Knowledge Domain 1.00 Knowledge 1.10 Knowledge of specifics 1.11 Knowledge of terminology 1.12 Knowledge of specific facts 1.20 Knowledge of ways and means of dealing with specifics 1.21 Knowledge of conventions 1.22 Knowledge of trends and sequences 1.23 Knowledge of classifications and categories 1.24 Knowledge of criteria 1.25 Knowledge of methodology

Intellectual Abilities and Skills Domain

17

1.30 Knowledge of the universals and abstractions in a field 1.31 Knowledge of principles and generalizations 1.32 Knowledge of theories and structures

Intellectual Abilities and Skills Domain 2.00 Comprehension 2.10 Translation 2.20 Interpretation 2.30 Extrapolation 3.00 Application 4.00 Analysis 4.10 Analysis of elements 4.20 Analysis of relationships 4.30 Analysis of organizational principles 5.00 Synthesis 5.10 Production of unique communication 5.20 Production of a plan or proposed set of operations 5.30 Derivation of a set of abstract relations 6.00 Evaluation 6.10 Judgements in terms of internal evidence 6.20 Judgement in terms of external evidence It is implicit in the taxonomy that to acquire a particular level of attainment one would have to have attained the levels below it first [11]. As well as allowing the setting of specific educational objectives, because each term relating to a specific objective has a rigidly defined meaning, the taxonomy allows those objectives to be aligned with the optimum instructional and assessment methods to deliver and assess that objective. Optimum instructional and assessment methods for each level were described in the book. Illustrative test items were included to demonstrate the task the student is expected to perform or the specific behaviour they are expected to exhibit. This ensures that assessment tools are aligned to the educational objectives to give clarity for the student and teacher in knowing what is expected of them (see Fig. 3.2) [12]. To illustrate the use of the taxonomy, we will take from the section “intellectual abilities and skills” the major class “comprehension” and the sub-class “extrapolation”. 2.00 Comprehension [13] 2.30 Extrapolation [14] Looking beyond the current date to predict future trends. Illustrative educational objectives: [15]. Filling in missing gaps in data. Recognising when assumptions applied to trending data are invalid.

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3 Learning

A L

Specific Educational Objective

I G N

Optimum Instructional Method

M E N T

Optimum Assessment

Fig. 3.2  Alignment of educational objectives, instructional methods and assessment Table 3.1  Anderson and Krathwohl’s revision to Bloom’s taxonomy [20] Cognitive Remember Understand Apply Analyze Evaluate Create Knowledge

Factual Conceptual Procedural Meta­cogni­tive

Illustrative test items [16]. Why may data on annual rates of flu in the population be inaccurate in predicting future flu rates? The definition of the sub-class “extrapolation” maps to the educational objectives which maps to the most appropriate testing methodology.

Anderson and Krathwohl’s Modification of Bloom’s Taxonomy In 2001, Anderson, Krathwohl and collaborators described a modification to Bloom’s taxonomy which addresses some of the problems encountered with operationalising the original taxonomy [17]. In recognition of the fact that the knowledge class was different from the other five cognitive classes, incorporating as it did both knowledge and the cognitive class remembering, Bloom divided his taxonomy into two sections, the knowledge section and the intellectual abilities and skills section [18]. Anderson and Krathwohl separated the two components of the knowledge class in taxonomy into the noun component (knowledge) and the verb component (cognitive). To represent this separation, they developed a two-dimensional representation of the revised taxonomy (see Table 3.1) [19].

Anderson and Krathwohl’s Modification of Bloom’s Taxonomy

19

Anderson and Krathwohl’s knowledge dimension was divided into 4 main types with 11 subtypes [21] (Bloom’s has three classes and nine sub-classes [22]). Their cognitive dimension was divided into six categories and nineteen processes [23] (Bloom’s has 5 classes and 11 sub-classes [24]). The cognitive category for knowledge in Anderson and Krathwohl’s taxonomy is remembered (verb form), which has two processes: recognizing and recalling [25]. The 4 types and 11 subtypes in Anderson and Krathwohl’s knowledge dimension: [26]. Knowledge Dimension A. Factual knowledge • Knowledge of terminology • Knowledge of specific details and elements B. Conceptual knowledge • Knowledge of classifications and categories • Knowledge of principles and generalizations • Knowledge of theories, models and structures C. Procedural knowledge • Knowledge of subject-specific skills and algorithms • Knowledge of subject-specific techniques and methods • Knowledge of criteria for determining when to use appropriate procedures D. Metacognitive knowledge • Strategic knowledge • Knowledge about cognitive tasks, including appropriate contextual and. • Self-knowledge The 6 categories and 19 processes in Anderson and Krathwohl’s cognitive dimension: [27]. Cognitive Dimension 1. Remember • Recognizing • Recalling 2. Understand • Interpreting • Exemplifying • Classifying • Summarizing • Inferring • Comparing • Explaining 3. Apply • Executing • Implementing

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3 Learning

4. Analyze • Differentiating • Organizing • Attributing 5. Evaluate • Checking • Critiquing 6. Create • Generating • Planning • Producing Anderson and Krathwohl posed four organising questions which the taxonomy can help to answer: [28]. 1. The learning question: What is it important to learn given limited time in the curriculum? 2. The instruction question: What is the best strategy for delivering effective learning? 3. The assessment question: What is the best assessment process to provide accurate information about the effectiveness of learning? 4. The alignment question: How are objectives, instruction and assessment best aligned?

The aims of the Anderson and Krathwohl revised taxonomy remain the same as Bloom’s, that is, to provide a common language for examiners to communicate [29]. The taxonomy can be used to construct very precise education objectives based on the format: The student will learn (cognitive process [verb]) to/of/with (knowledge subtype [noun]) [30]. This translates to (e.g.): The student will learn the names [to remember] of the capital cities of the European states [factual knowledge]. Because the verb and noun forms are precisely defined, there is absolute clarity about the meaning of the objective. The objective can be mapped to the knowledge and cognitive dimension in the chart to show at what level the objective is set (see Table 3.2 for the mapping of the example above) [31]. The instructional methods and assessment questions or methods can be framed in terms of the knowledge and cognitive dimensions to ensure precise alignment of objectives, instructional method and assessment [32]. Based on reviews of the literature on assessment, Krathwohl and Anderson suggested instructional methods or activities appropriate to each cognitive process or knowledge subtype [33].

Anderson and Krathwohl’s Modification of Bloom’s Taxonomy

21

Table 3.2  Mapping of objectives to the knowledge and cognitive dimensions

Knowledge

Cognitive Remember Understand Apply Analyze Evaluate Create x

Factual Conceptual Procedural Metacognitive

Relevant Facets of Professional Life

A L

Curriculum

I G

Educational Objective

N M Blue Print

E N

Instructional Method

T Assessment

Fig. 3.3  Construction and alignment of the elements of the curriculum

The taxonomy makes it possible to construct a curriculum which precisely defines each objective in terms of the knowledge and cognitive dimensions. Educational objectives for trainees (essentially a restatement of the curriculum) can be precisely aligned to the instructional methods appropriate to that level of the knowledge/cognitive dimension. Similarly, the assessment tools/methods appropriate for assessing that objective can be selected to maximize the likelihood that the student will complete their educational objectives and therefore pass their assessments. If the curriculum is an accurate map of the knowledge and skills required for a particular professional group, then the whole process will be aligned (see Fig. 3.3) [34].

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3 Learning

Anderson and Krathwohl’s modification of Bloom’s taxonomy has the potential to provide us with a method for assessing the stage of cognitive development of trainees. This can be achieved by mapping the type of knowledge and cognitive processes they exhibit onto the revised taxonomy and comparing them against those expected for a student in a specialty at a particular stage of development. It is however important to recognise the dynamic nature of learning. Progress may be uneven across different parts of the curriculum for any one trainee and individual trainees at the same level/stage of training will differ in their attainments. But by mapping to the taxonomy, it should be possible to tell whether a trainee is at a minimum acceptable level for their stage of learning and by serial monitoring whether they are progressing (Table 3.3 illustrates such a mapping). As an undergraduate, a student will learn the anatomy of the chest wall and thoracic contents; they remember factual knowledge. In later clinical practice, they will use this knowledge as the basis for acquiring the skill of inserting a chest drain; they apply procedural knowledge. The student has progressed both in terms of the complexity of the knowledge they have acquired and the cognitive processes they are using. This mapping process requires that we know the knowledge and cognitive processes required to be a doctor in a particular specialty. If this is poorly understood, then we can use the taxonomy definitions to map out the relevant subtypes of knowledge and the cognitive processes required for each specific sub-specialty in medicine. That will allow us to develop techniques for teaching them more effectively. The main changes Anderson and Krathwohl introduced to the revision of Bloom’s original taxonomy are: [35]. • The verb (cognitive process) and noun (knowledge type) components were separated into two dimensions. • The sub-classes of the knowledge dimension described by Bloom were framed in noun form as four types of knowledge. Table 3.3  Mapping of objectives to the knowledge and cognitive dimensions

Cognitive Remember Factual

K N O Conceptual W L E Procedural D G E Metacognitive

Understand

Apply

x

x

Analyze

Evaluate

Create

Anderson and Krathwohl’s Modification of Bloom’s Taxonomy

23

• The sub-classes of the cognitive dimension described by Bloom were framed in verb form as six types of cognitive processes. • Two of the original cognitive categories were renamed; comprehension becoming understand and synthesis becoming create. • The ordering of the top two categories was swapped round. This was based on a review of the evidence in the literature and the observation that induction, which underpins creating, is a more complex process than deduction. • Educational objectives were framed in terms of students being able to do (cognitive process [verb]) to/of/with (knowledge [noun]), a verb–noun relationship. In the original taxonomy, the Intellectual abilities and skills categories (the “being able to do something” part of the objective) and knowledge category were described in noun form. • There is more emphasis in the revision on the alignment of curriculum planning, instruction and assessment. • The previous view that the categories form a cumulative hierarchy was abandoned as adjacent categories may overlap. The types of explicit knowledge. The knowledge dimension of Anderson and Krathwohl’s modification of Bloom’s taxonomy allows us to describe the structure of explicit knowledge in terms of the 4 main types and 11 subtypes of knowledge. Note that the taxonomy only refers to explicit knowledge. It cannot be used to map tacit knowledge. As discussed above, it should be possible to map the types of explicit knowledge and cognitive processes required to be a doctor in any specific specialty using this or other taxonomies. This work has been done for the explicit knowledge required to be a doctor by many specialties but not for the cognitive processes. Bloom proposed that each major field should develop its own taxonomy reflecting its own structure and needs and develop new categories and combine or omit categories as appropriate [36]. It is important to be clear about the context in which the taxonomy is being applied as well as the prior knowledge and experience of a student to avoid errors in mapping. The following example illustrates this. Medical students first learn a list of the muscles of the forearm. In terms of the taxonomy table they remember factual knowledge. Later they begin to add structure to that list by classifying the muscles as flexors or extensors. They classify (a process in the understand category) their factual knowledge according to a classification system (a subtype of conceptual knowledge is knowledge of classifications and categories). In each case they are applying a cognitive process (verb) to the transformation of knowledge (noun) from one sub type to another; they are learning. If the student has learnt the classification from a textbook of anatomy they have not demonstrated the ability to classify knowledge, they have only demonstrated the ability to recall a classification. In order to demonstrate the ability to classify they must demonstrate that process with new knowledge or with the existing knowledge in a new context. This can be a potentially confounding factor when assessing the stage of cognitive development of a student as the mere ability to demonstrate

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Table 3.4  Mapping of objectives to the knowledge and cognitive dimensions Cognitive Remember Knowledge

Factual Conceptual Procedural Metacognitive

Understand B

Apply Analyze Evaluate Create

A

Characterisation by a Value or Value Complex

Organisation

Valuing

Responding

Receiving (Attending)

Fig. 3.4  Krathwohl’s taxonomy of the affective domain

knowledge of a classification system does not demonstrate the ability to classify. We can see in relation to Table 3.4 that (“A”) “remembering conceptual knowledge” derived from a textbook does not demonstrate the ability (“B”) to apply de novo the classifying process (a cognitive process of the understand cognitive category) to factual knowledge.

Affective Domain Krathwohl’s taxonomy of the affective domain was published in 1964. The taxonomy classifies the levels of engagement of a student with the learning process [37]. If the underlying organising principle of the cognitive section of Bloom’s original taxonomy is increasing complexity and of the knowledge section progression from the concrete to the more abstract knowledge, then the organising principle underlying the affective domain is internalisation [38]. Internalisation refers to the process of taking into oneself. English defined internalisation in terms of incorporating something into one’s mind [39]. The taxonomy of the affective domain has five categories (see Fig. 3.4) with 13 subdivisions.

Psychomotor Domain

25

The five categories and thirteen subdivisions of Krathwohl’s Taxonomy of the Affective Domain: [40].

Affective Domain 1.0  Receiving (Attending) 1.1 Awareness 1.2  Willingness to receive 1.3  Controlled or selected attention 2.0 Responding 2.1  Acquiescence in responding 2.2  Willingness to respond 2.3  Satisfaction in response 3.0 Valuing 3.1  Acceptance of a value 3.2  Preference for a value 3.3 Commitment 4.0 Organization 4.1  Conceptualization of a value 4.2  Organization of a value system 5.0  Characterization by a value or value complex 5.1  Generalized set 5.2 Characterization There is little emotional involvement at the receiving/responding stages; the individual is merely aware of the phenomenon in question. Emotional involvement becomes apparent and is in fact a critical component of the valuing/organization stages as the individual actively responds to the phenomenon. Full internalisation leads to loss of emotional involvement at the characterisation by value or value complex stages [41]. It is worth noting that while at the lower levels the degree of engagement of the student can be facilitated by the teacher, at the higher levels it is implicit that the individual has taken on full ownership of their engagement. The affective domain may be perceived as a driver to advancement.

Psychomotor Domain Bloom said that as so little had been done in relation to the psychomotor domain that working on a classification of objectives in this area would not be useful at this stage [42]. For the purpose of this chapter, I will use the pragmatic classification of the psychomotor domain implicit in the teaching of skills on courses such as the Advanced Trauma Life Support course and the European Paediatric Life Support course [43].

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“Stage 1  Animating clinical expertise Demonstration of the skill, performed at real speed with or without speech Stage 2  Reinforcing components of clinical expertise Repeat demonstration with dialogue, providing the rationale for actions Stage 3  Part transition of responsibility for the skill from instructor to candidate Repeat demonstration guided by one or more of the learners Stage 4  Independent candidate practice Repeat demonstration by the learner, and practice of the skill by all learners”.

Summary In summary, learning is an activity which results in a sustained change in behaviour. Learning can be subdivided into three domains. The cognitive domain considers the structure and function of explicit knowledge and cognitive processes including problem solving. The affective domain considers the degree to which an individual engages with the learning process. The psychomotor domain considers the physical elements of executing skilled behaviour. The cognitive domain allows alignment of educational objectives, curriculum, teaching methods and assessments to maximise the potential for a student to succeed. The knowledge dimension of the cognitive domain provides a structure for explicit knowledge. The psychomotor domain is poorly conceptualised but as a starting point the classification underpinning clinical resuscitation courses is offered. Krathwohl and Anderson’s modification to Bloom’s original taxonomy offers a tabular format to the cognitive domain which can be used to map out a student’s progress. In the next chapter, we will consider Experiential Learning Theory.

References 1. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR.  Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company; 1972. p. 4. 2. Anderson LW, Krathwohl DR, editors. A taxonomy for learning, teaching and assessing: a revision of Bloom’s taxonomy of educational objectives. New York: Longman; 2001. p. xxvii. 3. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR.  Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company; 1972. p. 7. 4. Ibid. p. 12. 5. Ibid. p. 201. 6. Ibid. p. 204. 7. Ibid. p. 62. 8. Ibid. p. 16. 9. Ibid. p. 30. 10. Ibid. p. 201–207. 11. Ibid. p. 18.

References

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12. Ibid. p. 21–22. 13. Ibid. p. 204. 14. Ibid. p. 205. 15. Ibid. p. 96. 16. Ibid. p. 119. 17. Anderson LW, Krathwohl DR, editors. A taxonomy for learning, teaching and assessing: a revision of Bloom’s taxonomy of educational objectives. New York: Longman; 2001. 18. Bloom BS, (Ed). Engelhart MD, Furst EJ, Hill WH, Krathwohl DR. Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company; 1972, p. 201. 19. Anderson LW, Krathwohl DR, editors. A taxonomy for learning, teaching and assessing: a revision of Bloom’s taxonomy of educational objectives. New York: Longman; 2001. p. 4–5. 20. Ibid. p. 28. Anderson Lorin W, Krathwohl, David R, Airasian, Peter W, Cruikshank, Kathleen A, Mayer, Richard E, Pintrich, Paul R, Raths, James, Wittrock, Merlin C.  A taxonomy for learning, teaching, and assessing: a revision of bloom's taxonomy of educational objectives, complete edition, 1st edn. ©2001. Reprinted by permission of Pearson Education, Inc., New York, NY. 21. Ibid. p. 29. 22. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR. Taxonomy of educational objectives: the classification of educational goals. Handbook I: cognitive domain. New York: David McKay Company; 1972. p. 201–4. 23. Anderson LW, Krathwohl DR, editors. A taxonomy for learning, teaching and assessing: a revision of Bloom’s taxonomy of educational objectives. New York: Longman; 2001. p. 31. 24. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR. Taxonomy of educational objectives: the classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company; 1972. p. 204–5. 25. Anderson LW, Krathwohl DR, editors. A taxonomy for learning, teaching and assessing: a revision of Bloom’s taxonomy of educational objectives. New York: Longman; 2001. p. 31. 26. Ibid. p. 46. 27. Ibid. p. 67–68. 28. Ibid. p. 6. 29. Ibid. p. 302. 30. Ibid. p. 307. 31. Ibid. p. 32. 32. Ibid. p. 37. 33. Ibid. within body of text in relevant sections. 34. Ibid. p. 250–256. 35. Ibid. p. 305–312. 36. Ibid. p. xxvii–xxviii. 37. Krathwohl DR, Bloom BS, Masia BB.  Taxonomy of educational objectives: the classification of educational goals. Handbook II: the affective domain. New  York: David McKay Company; 1964. 38. Ibid. p. 28. 39. English Horace and English Ava, C. A comprehensive dictionary of psychological and psychoanalytical terms. New York: David McKay, pp. 272; 1958. 40. Krathwohl DR, Bloom BS, Masia BB. Taxonomy of educational objectives: The classification of educational goals. Handbook II: the affective domain. New York: David McKay Company; 1964. p. 176–85. 41. Ibid. p. 30. 42. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR. Taxonomy of educational objectives: the classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company; 1972, p. 7. 43. Bullock I, Davis M, Lockley A, Mackway-Jones K. Pocket guide for clinical instructors (3rd edn.). Chichester: Wiley Blackwell (BMJ Books); 2015, pp. 29–31. From Bullock I, Davis M, Lockley A, Mackway-Jones K.  Pocket guide for clinical instructors (3rd edn.). Chichester: Wiley Blackwell (BMJ Books); 2016. © 2016. Reprinted by permission of John Wiley and Sons, Publishers.

4

Experiential Learning Theory

Experiential Learning Theory (ELT) developed from the work of Dewey, Lewin and Piaget in the twentieth century [1–3]. More recently ELT has come to be synonymous with the name of David Kolb. Kolb has done much to extend ELT and develop an evidence base for its application and practice. Kolb defines experiential learning as the main process by which humans adapt to their environment [4]. Based on his work, Kolb offers a formal definition of learning [5]: “Learning is the process whereby knowledge is created through the transformation of experience”1.

The key concept in Kolb’s definition is that learning and therefore knowing only occurs through the transformation of experience. To transform experience, we first need to perceive (grasp) the experience and then we need to transform it. The mere grasping of experience is not enough, something must be done with it [6]. Kolb describes the transformation of experience in terms of two dimensions, each with two opposing modes [7]: • The prehension (perception or grasping) dimension involves grasping experience through two dialectically2 opposed modes [8, 9]: –– Apprehension mode: this describes the global sensation or feel of the experience. –– Comprehension mode: this involves the naming and describing of the experience. The process of naming and describing leads to some loss of definition of the globally apprehended experience. 1  But see my definition heading the chapter on Learning which see learning in terms of outputs, namely a change in behavior. 2  A dialectic describes two opposing views (thesis and antithesis) which, through a process of examination, discussion, etc., are resolved through a compromise position called a synthesis: thesis–antithesis = synthesis.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_4

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• The transformation (processing) dimension involves transforming the grasped experience through two dialectically opposed modes of transforming experience [10, 11]: –– Intention mode: internal reflection. –– Extension mode: active manipulation of the external world. Diagrammatically, these are placed on two perpendicular axes (see Fig. 4.1). Since knowledge is created by the transformation of experience and there are two transformation modes and two grasping modes it follows that there must be four types of knowledge (see Fig. 4.2) [12]: • Divergent knowledge: the product of experience grasped through apprehension and transformed by intention. • Assimilative knowledge: the product of experience grasped through comprehension and transformed by intention. • Convergent knowledge: the product of experience grasped through comprehension and transformed by extension. • Accommodative knowledge: the product of experience grasped through apprehension and transformed by extension.

Apprehension Mode

Grasping Dimension

These elementary forms of knowledge are the building blocks for developing higher levels of knowing [13].

Extension Mode

Intention Mode

Comprehension Mode

Transforming Dimension

Grasping Dimension

Transforming Dimension

Fig. 4.1  The two dimensions and two modes for transforming experience

Apprehension

Accommodative Knowledge

31

Grasping by

4  Experiential Learning Theory

Transforming by

Divergent Knowledge

Transforming by

Convergent Knowledge

Assimilative Knowledge

Comprehension

Intention

Grasping by

Extension

Fig. 4.2  The four types of knowledge derived by the transformation of experience

Kolb describes the process of experiential learning as a four stage cycle involving four adaptive learning modes (see Fig. 4.3) [14]: • Concrete Experience (CE): the learning mode characterized by grasping experience through apprehension. • Reflective Observation (RO): the learning mode characterized by transforming experience through intention. • Abstract Conceptualization (AC): the learning mode characterized by grasping experience through extension. • Active Experimentation (AE): the learning mode characterized by transforming experience through intention. These four adaptive learning modes combine to produce four first-order learning styles (see Fig. 4.4) [15]: • Diverging (CE/RO): grasping experience through apprehension (Concrete Experience) and transforming it through intention (Reflective Observation). • Assimilating (AC/RO): grasping experience through comprehension (Abstract Conceptualisation) and transforming it through intention (Reflective Observation).

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4  Experiential Learning Theory

Apprehension

Grasping by

Accommodative Knowledge

Divergent Knowledge

Convergent Knowledge

Assimilative Knowledge

Comprehension

Transforming by Intention

Grasping by

Transforming by Extension

Reflective Observation

Active Experimentation

Concrete Experience

Abstract Conceptualisation

Fig. 4.3  The four adaptive learning modes

Apprehension

Accommodative Knowledge

Comprehension

Convergent Learning Style

Divergent Knowledge Transforming by Intention

Grasping by

Transforming by Extension Convergent Knowledge

Divergent Learning Style

Reflective Observation

Active Experimentation

Accommodative Learning Style

Grasping by

Concrete Experience

Assimilative Knowledge

Assimilative Learning Style

Abstract Conceptualisation

Fig. 4.4  The four first-order learning styles

• Converging (AC/AE): grasping experience through comprehension (Abstract Conceptualisation) and transforming it through extension (Active Experimentation). • Accommodating (CE/AE): grasping experience through apprehension (Concrete Experience) and transforming it through extension (Active Experimentation).

First-Order Learning Strategy

33

Learning Style Inventory Assessing individual learning styles: The Learning Style Inventory [16]. Kolb developed the Learning Styles Inventory (LSI) to determine an individual’s preferred learning style. The LSI consists of nine questions each with four words corresponding to one of the four learning modes. The respondent is asked to rank the four words, e.g.: • • • •

Concrete Experience (feeling) Reflective Observation (watching) Abstract Conceptualisation (thinking) Active experimentation (doing)

The responses indicate the person’s relative preference for each of the four learning styles. There are two further scores. One assesses the individual’s preference for abstract over concrete thought (AC–CE) and the other assesses preference for action over reflection (AE–RO). Although learners tend to have preferred learning styles, to be effective they need to use all four learning modes. They need to gain new experiences (CE), they reflect on those experiences (RO), they generate theories to link their observations and reflections (AC) and use those theories to facilitate decision-making and problem-­ solving (AE) [17]. Kolb describes three hierarchical orders of learning strategy which he demonstrates with reference to a person learning to play pool:

First-Order Learning Strategy The first-order learning strategies involves combining two adjacent learning modes: one from the grasping dimension and one from the transforming dimension [18]. Comprehension–Extension (AC–AE): The player uses their knowledge of physics (angle of incidence equals angle of reflection) to inform the setting up of the shot. They may use the cue to visually map the angles out. Apprehension–Extension (CE–AE): The player uses their intuition for what the “right” alignment is and may experiment with several until the one that “feels” right is selected. Apprehension–Intention (RO–CE): The player uses knowledge gained from watching their opponent’s shots to inform their choice of alignment. The alignments resulting is successful shots are replicated; those from unsuccessful ones are adjusted. Comprehension–Intention (RO–AC): The player tries to develop rules for applying “spin” to the ball based on an iterative process informed by the success of their shots and their opponent’s shots.

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Second-Order Learning Strategy The second-order learning strategies involve combining two adjacent first-order learning modes [19]. • • • •

Apprehension–Intention–Comprehension (CE–RO–AC) Intention–Comprehension–Extension: (RO–AC–AE) Comprehension–Extension–Apprehension (AC–AE–CE) Extension–Apprehension–Intention (AE–CE–RO)

Kolb gives as an example AE–CE–RO where the player takes what they “feel” is the “right” shot (Apprehension–Extension: CE–AE) but then observes where the ball rolls and the success of the shot (Apprehension–Intention: CE–RO). The combination of the two learning strategies produces a higher level of learning (Extension–Apprehension– Intention: AE–CE–RO) than either of the two first-order strategies alone [20].

Third-Order Learning Strategy The combination of all four of the first-order learning strategies produces the highest level of learning. Few of us use third-order learning strategies in most day-to-day situations. Mostly we rely on our preferred first-order strategy. However, when our preferred strategy fails to give the results, we want we can try other first-, second- or third-order strategies [21].

Nine Learning Styles and Four Dialectic Tensions The latest version, the Kolb Learning Style Inventory 4.0 (KLSI 4.0) has increased the original four styles to nine styles. Summary of the nine learning styles (see Fig. 4.5) [22]. • The Initiating Style action is initiated to deal with situations. AE–CE. • The Experiencing Style: meaning is derived from experience. AE–CE–RO. • The Imagining Style: possibilities are imagined by observing and reflecting on experiences. CE–AC. • The Reflecting Style: experience and ideas are integrated through reflection. CE–RO–AC. • The Analysing Style: ideas are integrated and structured through reflection. RO–AC. • The Thinking Style: abstract and logical reasoning are the focus. RO–AC–AE. • The Deciding Style: theories and models are used to generate solutions and action. AC/AE. • The Acting Style: people and tasks are combined. AC–AE–CE. • The Balancing Style: acting/reflection and experimenting/thinking are adapted and balanced. CE–RO–AC–AE.

Learning Flexibility

35 Concrete Experience

Diverging

Accommodating

Experiencing Initiating

Active Experimentation

Acting

Imagining

Balancing

Deciding

Reflecting

Reflective Observation

Analysing Thinking

Converging

Assimilating

Abstract Conceptualisation

Fig. 4.5  The Nine KLSI 4.0 learning styles and four dialectic tensions

In addition to the nine KLSI 4.0 learning styles, there are four dialectic tensions [23]: Primary (grasping and transforming) • Abstract Conceptualisation/Concrete Experience • Active Experimentation/Reflective Observation Secondary • Assimilation/Accommodation • Converging/Diverging

Learning Flexibility This describes the ability of a learner to move around the learning cycle using each of the four learning modes modifying their approach based on the learning situation [24, 25]. The KLSI 4.0 assesses learning flexibility by incorporating the Adaptive

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4  Experiential Learning Theory

Initiating

Experiencing

Imagining

Acting

Balancing

Reflecting

Deciding

Thinking

Analyzing

Reflective Observation

Active Experimentation

Concrete Experience

Abstract Conceptualisation

Fig. 4.6  The backup styles for low learning flexibility learners

Initiating

Experiencing

Imagining

Acting

Balancing

Reflecting

Thinking

Analyzing

Deciding

Reflective Observation

Active Experimentation

Concrete Experience

Abstract Conceptualisation

Fig. 4.7  The backup styles for high learning flexibility learners

Style Inventory (ASI) which measures how individuals change their learning style in response to different situations [26]. Research has also demonstrated “backup” styles for low and high flexibility learners (see Figs. 4.6 and 4.7) [27]: High flexibility individuals tend to show more backup styles and hence a greater ability to move around the learning cycle.

Summary In summary, experiential learning is one of the central processes of human adaptation to the social and physical environment. It involves the transformation of experience to generate new knowledge. The theory describes nine learning styles which can be assessed using the Learning Style Inventory. In the next chapter, we will consider the neurophysiological basis of learning and memory.

References

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References 1. Dewey J. Experience and education. New York: Kappa, Delta, Pi; 1938. 2. Lewin K. Filed theory in social sciences. New York: Harper and Row; 1951. 3. Piaget J. Genetic epistemology. New York: Columbia University Press; 1970. 4. Kolb, David A. Experiential learning: experience as the source of learning and development. New Jersey, Prentice-Hall, pp. 31. 1984. 5. Kolb, David A. Experiential learning: experience as the source of learning and development. New Jersey, Prentice-Hall, pp. 25. 1984. 6. Ibid. p. 42. 7. Ibid. p. 40–41. 8. Ibid. p. 58. 9. Ibid. p. 43–44. 10. Ibid. p. 59. 11. Ibid. p. 51–52. 12. Ibid. p. 42. 13. Ibid. 14. Ibid. p. 40–41. 15. Ibid. p. 64–65. 16. Ibid. p. 67–69. 17. Ibid. p. 31–32. 18. Ibid. p. 64–66. 19. Ibid. p. 65–66. 20. Ibid. p. 66. 21. Ibid. 22. Kolb, David A. Experiential learning: experience as the source of learning and development. New Jersey, Pearson Education. pp. 145. 2015. 23. Ibid. 24. Ibid. pp. 146–147. 25. Ibid. pp. 147–148. 26. Ibid. pp. 149–150. 27. Ibid. pp. 150–151.

5

Brain Plasticity, Learning and Memory

It goes without saying that there can be no learning without memory. Memory is the record of what has been learned. If learning is an activity which leads to a sustained change in behaviour, then memory is the storage or recording of that learning. Both activities result in structural changes in the brain as a consequence of brain plasticity.

Learning Plasticity is the term used to describe the ability of the brain to modify its organisation and function throughout the lifetime of an individual. In relation to adult learners, changes in behaviour (learning) are associated with changes in the number of dendrites, synapses and spines. This results in the formation of new neural networks or the modification or removal of existing networks. Dendrites and spines exhibit temporary or permanent plastic changes in response to their history of stimulation and can form new synapses in hours or even minutes. An increase in stimulation of a particular group of neurons leads to an increase in the density of their dendrites, synapses and spines. Conversely a decrease in stimulation leads to a decrease in density. It is a common experience that once we have learned a new skill we can, in the most part, carry out that skill or action without consciously thinking about it. The establishment of a neural pathway as a result of recurrent stimulation of the neurons linking the areas of the brain required to execute that skill effectively hardwires the process for executing that skill in our brain [1, 2].

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_5

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5  Brain Plasticity, Learning and Memory

Memory Memory can be classified as explicit (declarative) and tacit (non-declarative). Explicit memory inhabits the conscious domain while tacit memory inhabits the subconscious domain [3]. There are two sorts of memory, short-term memory, where retention of data lasts seconds to hours and long-term memory, where retention of data lasts for many years. Short-term memory has a subdivision called working memory where information is held while it is being processed [4]. Working memory has two rehearsal systems; a visuospatial sketch pad system and a phonological (auditory) rehearsal system both managed by a central executive function [5]. The function of the phonological rehearsal system can be likened to the repetition of a short shopping list during the journey from home to a shop. In addition to being held in the visuospatial sketch pad system, visuospatial information can also be rehearsed in the phonological system by silently verbalising it. The two systems can operate at the same time without interfering with one another (see Fig. 5.1) [6–8].

Short Term Memory

Working Memory

Long Term Memory

Fig. 5.1  The relationship between long-term, short-term and working memory

Summary

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VisuoSpatial Scratch Pad

Input

Sensory Memory

Central Executive

Long Term Memory

Decay Phonological Loop

Fig. 5.2  The relationship between the components of working memory and long-term memory

There are two main differences between long-term memory and short-term memory; their physical capacity to hold information and the time over which information can be retained before it decays (see Fig. 5.2). Short-term memory has a very limited capacity called chunk capacity. Miller proposed that the capacity of short-term memory was seven items plus or minus two. Information within short-term memory decays with time or is displaced by other information. The evidence for temporal decay is weaker than for chunk capacity [9]. Due to chunk capacity limits, data in our short term memory is only held for as long as it is required. As soon as it has fulfilled its purpose it is committed to long-­ term memory or is lost to make room for new data to process. Our short-term memory is constantly undergoing a process of housekeeping in order to make the best use of its limited capacity. Long-term memory has a vast capacity, with the ability to retain information encoded in it for extended periods and in some instances for the entire duration of an individual’s life [10].

Summary In summary, learning leads to the establishment of “hardwired” neural networks resulting from an increase in dendrite, spine and synaptic density. This is a result of repeated stimulation of a neural pathway during the learning process. Memory is the record of that learning and consists of short-term memory, working memory and long-term memory. The content of short-term

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5  Brain Plasticity, Learning and Memory

memory is limited to about seven items which decay (“are forgotten” or displaced by new content) within seconds if not retained within working memory. Working memory is a sub-section of short-term memory, where content is retained by rehearsal in the phonological loop or in the visuospatial scratch pad while it is being processed. Long-term memory has a vast capacity and can retain content sometimes for the life of the individual. In the next chapter, we will discuss the environmental factors which influence learning.

References 1. Barrett KE, Barman SM Boitano S, Brooks H. Ganong’s review of medical physiology, 25th edn. Chapter 15, p. 286–7. New York: McGraw-Hill; 2016. 2. Kolb B, Gibb R. Searching for the principles of brain plasticity and behavior. [Review]. Cortex. 2014;58:251–60. 3. Barrett KE, Barman SM Boitano S, Brooks H. Ganong’s review of medical physiology, 25th edn. Chapter 15, p. 283–284. New York: McGraw-Hill; 2016. 4. Ibid. p. 285. 5. Ibid. p. 288. 6. Baddeley AD.  Working memory: theories, models, and controversies. Annu Rev Psychol. 2012;63:1–29. 7. Hofmann W, Schmeichel BJ, Baddeley AD. Executive functions and self-regulation. [Review]. Trends Cogn Sci. 2012 Mar.;16(3):174–80. 8. Cowan N.  What are the differences between long-term, short-term, and working memory? Prog Brain Res. 2008;169:323–38. 9. Baddeley A, Eysenck MW, Anderson MC.  Memory, 2nd edn. pp  43. Sussex: Psychology Press; 2015. 10. Ibid. pp. 13.

6

Constructivism and Objectivism

Objectivism and Constructivism Duffy and Jonassen [1] discuss the two major traditions in education: objectivism and constructivism. Both traditions hold that reality (the world and meaning) exists independent of our experience: • Objectivism: Because we all come to a learning situation with different background experiences, we all start off from a different perspective. This prior experience can tend to lead to an incomplete or biased understanding of the world. It is the function of the educational system to provide students with a complete and correct understanding of the world. • Constructivism: Because we all come to a learning situation with different background experiences, we all start off from a different perspective. This prior experience leads us to impose our own meaning on the world. There is no “correct” meaning to be learned. Although described as two traditions, if we consider objectivism and constructivism in the light of Anderson and Krathwohl’s taxonomy, we can consider them as two extremes of a spectrum [2]: Objectivism Remembering factual knowledge

→

Constructivism Creating metacognitive knowledge

The lower levels of knowledge and cognition, (e.g. remembering factual knowledge) are more appropriately described in terms of objectivism (e.g. a metre is a metre), where there is less scope for interpretation. The higher levels of knowledge and cognition (e.g. creating metacognitive knowledge) are more appropriately described in terms of constructivism (e.g. beauty is in the eye of the beholder) where there is greater scope for interpretation. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_6

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In the traditional medical curriculum where preclinical and clinical phases are separated, objectivism would best characterise the preclinical phase as the student works to commit to memory the large volume of factual and conceptual knowledge required to progress to the clinical phase. The transition to constructivism would best characterise the clinical stage as the student learns to apply the basic and applied sciences to the real-world clinical environment.

 onstructivism, Cognitive Constructivism, C Social Constructivism Constructivism holds that we each construct our own map of reality based on our own unique experiences. When we encounter new knowledge or phenomena, we have to reconcile these with our current model of reality. There are two broad schools of constructivist thought: 1. Social constructivism: Deals with factors in the learning environment which facilitate an individual constructing their own map of reality. The work of Lev Vygotsky and Jerome Bruner is associated with this tradition. 2. Cognitive constructivism: Deals with the processes occurring in an individual’s brain when they are constructing their own map of reality. The work of Jean Piaget is associated with this tradition.

Lev Vygotsky (1896–1934) Vygotsky was a Soviet psychologist whose interests included the fields of developmental psychology, child development and education. From our perspective, Vygotsky advanced two useful concepts, which, although developed in relation to the acquisition of language by children, are equally applicable to the adult learning process.

The Zone of Proximal Development (ZPD) Vygotsky describes the Zone of Proximal Development (ZPD) as: “The distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under average guidance or in collaboration with More Capable Peers” [3].

More Capable Peer The More Capable Peer, or More Knowledgeable Other (MKO) as it is now more widely known, refers to someone who has a better understanding or higher ability level than the learner. The MKO may be another adult, a peer, a textbook or an

Assimilation: “Fit Practice to Theory”

45

internet web site. The essence of the MKO is that they have more knowledge about the topic under discussion than the learner does [4]. More Knowledgeable Other Knowledge 1 Knowledge 2 → ←Zone of Proximal Development→

The MKO is the intermediary by which learning is externally facilitated. In Vygotsky’s words [5], “What the child is able to do in collaboration today he will be able to do independently tomorrow”.

Jerome Bruner (1915–2016) Bruner, an American psychologist coined the term scaffolding. The scaffold is temporary support provided by a teacher or a more competent peer to a student to bridge the ZPD. Like a scaffold, the support is removed when it is no longer required [6].

Jean Piaget (1896–1980) Piaget was a Swiss philosopher and natural scientist whose theory of cognitive development was his main work. The specific aspect of his work relevant to us in postgraduate medical education is the work he did in relation to child development. Like the work of Vygotsky, Piaget’s work is equally applicable to the postgraduate environment. First, we need to understand Piaget’s terminology [7, 8].

Schema Piaget’s Schemas Our behaviour is mediated by our mental schemas which can be thought of as plans with a series of steps aimed at achieving a specified end (see Fig. 6.1). When we encounter new information, we must reconcile this to our schemas; this can occur in several ways.

Assimilation: “Fit Practice to Theory” The process by which a person takes in new information from the outside world without changing their current schema, that is the evidence either fits or is made to fit the schema.

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6  Constructivism and Objectivism Piaget’s Schema

New Knowledge

Not Congruent with Current Schema

Congruent with Current Schema

Assimilation

Accommodation

Current Schema

New Schema

Fig. 6.1  Schematic of Piaget’s Schema

Accommodation: “Fit Theory to Practice” The process by which a person changes their current schema to fit with new information taken in from the outside world, that is the schema is changed to fit the evidence.

Adaptation Piaget described the achievement of internal equilibrium through adaptation by a process of accommodation and assimilation. In practice assimilation and accommodation work in tandem. Having summarised the differences between cognitive and social constructivism, we will now consider the similarities.

Jonassen’s General Characteristics of Constructivist Learning Environments Jonassen [9] summarised the general characteristics of all constructivist learning environments which emphasise a collaborative rather than competitive approach to the development of individualised personal knowledge. This is achieved through exposure to multiple context specific true world experiences in real-world settings or through case-based learning, rather than through traditional context free abstract rote learning. This approach better represents the true complexity of reality and facilitates reflection on experiences.

A Word About Aptitude

47

Eraut’s Routinisations Eraut, in relation to teaching, describes a concept akin to Piaget’s schemas which he calls “routinisations”. Teachers have to develop routines to be able to cope with the rapidly changing circumstances in the classroom [10]. It can be difficult however to change routinisations in practice as the practitioner, at the same time as having to manage the classroom environment, has to “unlearn” what they have learnt and incorporated into their routinisations. This unlearning is an essential prelude to their learning new routines and moving forward in their professional development. Eraut describes the feeling of disorientation which teachers can experience during this process and notes that there is a risk that they will consciously decide not to change their routinisation [11]. We should acknowledge the importance of schemas or routinisations in professional practice as they allow us to cope with a busy working life without having to recurrently work out the solution to the same problems or clinical scenarios time and again. There is a balance to be had between constantly changing one’s management of a condition in the light of each new piece of evidence and failing to adapt to a changing evidence base. A little inertia in the system of change makes for a stable platform for professional practice.

A Word About Aptitude The term “aptitude” is often used to denote innate ability. The assumption being that an individual without innate ability or innate ability of sufficient degree to perform a particular skill can never develop that skill. If we consider aptitude in terms of the work of Vygotsky, we can see that an individual may have more potential than is initially evident but may require assistance or “scaffolding” from an MKO to help them transit the ZPD and attain their true potential. Once that potential has been realised the scaffolding can be removed. The ZPD defines the difference between what an individual can achieve alone and what their maximal potential is when assisted by an MKO. The MKO facilitates the attaining of the individual’s true potential. We all recognise scenarios involving trainees where insufficient support through their developmental phases (either in training or in postgraduate professional development) may consign them to failure, where a process of support (whether mentoring or coaching) can provide the scaffolding to allow them to transit their ZPD. That support is predicated on our understanding of what their specific needs are. This depends on our understanding of what knowledge, cognitive processes, psychomotor skills and level of affective engagement are required for a doctor to function at a specific level in a given sub-specialty and working environment.

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Summary In summary, there are two major traditions in education, constructivism and objectivism, each holds that there is a reality independent of our existence. Objectivism holds that the function of the educational system is to facilitate each learner to reproduce an accurate map of that reality in the learner’s brain. Constructivism holds that the function of the education system is to facilitate each learner constructing their own model of that reality. Each has a role to play in understanding how learning occurs. Constructivism has two schools, cognitive constructivism which deals with the cognitive processes underlying learning and social constructivism which deals with the environment in which learning occurs. The transformation of thought into action can be described in terms of mental schemas or routinisations which are effectively mental plans of action. Learners respond to new information by adapting their mental plan in response to the new information or by taking the new information as supporting evidence for their current mental plan. In the next chapter, we will consider how skills are acquired, developed and refined.

References 1. Duffy MT, Jonassen DH. Constructivism and the technology of instruction: a conversation. London: Routledge; 1992. p. 2–3. 2. Ibid. p. 138. 3. Vygotsky LS. Mind in society: the development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978, p.  86. Mind in society: development of higher psychological processes by L.  S. Vygotsky, edited by Michael Cole, Vera John-Steiner, Sylvia Scribner, and Ellen Souberman, Cambridge, MA: Harvard University Press, Copyright © 1978 by the President and Fellows of Harvard College. 4. Ibid. p. 86. 5. Vygotsky LS. Thinking and speech (N. Minick, Trans.). In Rieber RW, Carton AS. editors. The collected works of L. S. Vygotsky: Vol. 1. Problems of general psychology. New York: Plenum Press; 1987, p. 211. (Original work published 1934). 6. Wood DJ, Bruner JS, Ross G.  The role of tutoring in problem solving. J Child Psychiatry Psychol. 1976;17(2):89–100. 7. Piaget J. The psychology of intelligence. London: Routledge; 2001, p. 8–10. (Originally published 1947). 8. Piaget J, Cook MT.  The origins of intelligence in children. Middlesex, England: Penguin; 1983, p. 15–20. (Originally published 1936). 9. Jonassen DH.  Thinking technology: toward a constructivist design model. Educational Technology. 1994;34(4): 34–37.**. 10. Eraut M. Developing professional knowledge and competence. London: Falmer Press; 1994. p. 53–4. 11. Ibid. p. 112.

7

Skill

When considering skill acquisition, it is helpful to start with the work of Stuart Dreyfus, a mathematician and system analyst and his brother Hubert Dreyfus, a philosopher. Hubert and Stuart Dreyfus were employed by the US Air Force to research into methods for training pilots. One output of that project was their development of a model to describe the stages of skill acquisition. Patricia Benner, an academic nurse, applied the Dreyfus and Dreyfus model to nursing practice and found a good fit with the stages of skill acquisition in nurses. Dreyfus and Dreyfus found that as people acquire a new skill they advance through five distinct stages which they termed novice, advanced beginner, competent, proficient and expert (see Fig. 7.1). When people progress through these stages

Expert

Proficient

Competent

Advanced Beginner

Novice

Fig. 7.1  Dreyfus and Dreyfus model of skill acquisition © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_7

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7 Skill

their view of the task in hand and their decision making processes change [1]. These different stages reflect changes in three components of skilled performance: [2]. • A transition from decision-making based on abstract rules to decision-making based on prior experience [the reverse of the Piagetian view on how children develop skills [3]. • A transition in the perception of the task environment from one which is composed of many elements all of which contribute equally to the decision-making process to one where only a few elements are relevant and their contributions to the decision-making process are assigned varying weighting. • A transition from the performer applying abstract rules to objective elements with no emotional attachment to the outcome to that of a performer who is intimately involved in the decision-making process and has a high degree of emotional “buy-in” to the outcome. The Dreyfus model concerns itself with the commonest type of decision-making process which they called “unstructured”. Unstructured problems have a large number of factors that must be taken into account when deciding on how to act. The ways these factors interact and impact on other events are difficult to predict. Dreyfus and Dreyfus gave as examples of unstructured areas of practice, management, nursing, clinical medicine, teaching and social interactions [4]. Dreyfus and Dreyfus gave as examples of “structured areas” of decision-making, solving mathematical equations, completing puzzles, the routeing of delivery trucks and petrol blending. Here the desired outcome is defined and the factors to be manipulated to achieve that outcome are known [5]. Acquiring a high level of skill in unstructured problem solving requires extensive experience of working in actual situations. An individual will therefore exhibit a range of skill levels across a number of types of situations [6]. A surgeon, for example, may show expertise at operating, while at the same time being only competent as a diagnostician and a mere novice when it comes to planning services. Dreyfus and Dreyfus noted that not all people achieve expertise in all skills. Almost anyone can become an expert at driving, while few ever become an expert at chess. Even within a given stage of skill acquisition there will be different levels of attainment. Not all individuals at a specific stage of attainment are equally skilled. The term “stage” is used because individuals acquiring a new skill have been observed to follow the five stages and those individuals performing at the highest level of one stage will outperform those at the highest level of a lower stage [7]. Note that the model distinguishes between the level of attainment that can be reached through classroom learning (trait: “knowing that”) and the experiential skills that can only be learnt in actual practice (situational: “knowing how”). For example, an expert consultant in adult intensive care would be a novice if they transferred to neonatal intensive care [8]. In the following description of the five stages, the narrative explaining each stage will be followed by a description of the characteristic features of that stage in relation to acquiring the skills needed to drive a car (Dreyfus and Dreyfus).

Advanced Beginner

51

The terminology applied to describe the components of the model has varied during its development. In the description of the model given below, I have selected the terms and definitions which best map to the description of the model as applied to medical practice (e.g. I have used the term paradigm which was dropped in later descriptions of the model as it maps well to the concept of a specific diagnostic entity). We will now consider the acquisition of a new skill stage by stage.

Novice The novice in the early stages of acquiring the skill required to work in a new situation has no prior experience to tell them what is relevant and what is not. To help them gain such experience an instructor starts by breaking the situation down into a number of objective, context free, elements called features. The instructor gives the novice rules to apply to these features to decide what actions to take. Dreyfus and Dreyfus call such elements non-situational to reflect that their application is not reliant on the situation or context in which they are being used [9]. “The student automobile driver learns to recognise such context free features as speed (indicated by the speedometer) and is given rules such as shift to second gear when the speedometer needle points to ten”. [10]

Features + Rules → Actions Note that at this stage the novice is not told that it is permitted not to follow the rules in certain circumstances [11]. To progress the novice needs monitoring to ensure absolute adherence to the rules [12]. While gaining experience of working in, and dealing with, the actual situations in which the skill is to be applied, the novice acquires an increasing number of features and rules. This practical experience is essential as an understanding of the context in which the elements make sense is required for progression to the next stage of development [13].

Advanced Beginner The advanced beginner, with experience of working with actual situations, starts to observe or is shown a new class of element which cannot be objectively defined in the way features can, but can only be recognised within the context of the situation. Such situational elements are called aspects [14]. The aroma of coffee is an aspect. The description of the aroma cannot be adequately conveyed in words, but a single exposure to the aroma will commit it to memory for life [15]. Aspects and features are combined to produce guidelines which determine appropriate actions. Guidelines assign an equal weighting to all elements (features and aspects) and are constructed to include as many as possible [16].

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Since aspects can only be defined in relation to the specific situation in which they are found, situational understanding is a prerequisite to aspect recognition [17]. Therefore a guideline, unlike a rule, requires situational understanding before it can be used because it incorporates aspects in the decision-making process. “The advanced beginner driver uses (situational) engine sounds as well as (context free) speed in deciding when to change gear. He learns the guideline: shift up when the motor sounds like its racing and down when it sounds like its straining. Engine sounds cannot be adequately captured by a list of features. In general, features cannot take the place of a few choice examples in learning the relevant distinctions”. [18]

Elements (Features + Aspects) → Rules + Guidelines → Actions Benner advocates that as the advanced beginner cannot yet recognise what is most important they need support in the clinical setting by staff of at least competent practitioner level to ensure patient care is not compromised [19].

Competence As the advanced beginner gains further experience and acquires an increasing number of features, aspects, rules and guidelines they may feel overloaded with the amount of information they have to process to determine the correct action to take [20]. To manage this information overload, the competent practitioner has to impose some order on the situation. This they do by consciously deciding on a goal and making a plan to achieve that goal. A plan determines the perspective from which the competent practitioner views the situation, which in turn defines the elements of that situation which are important [21]. The competent practitioner working from a particular perspective sees the situation as a set of elements (features and aspects) of varying salience (relative importance in relation to each other). Like the advanced beginner, they combine these elements using rules and guidelines to determine the actions to be taken, but unlike the advanced beginner they weigh up the relative importance of the elements when coming to a decision [22]. Taking a perspective allows the competent practitioner to reduce the situation to a manageable number of elements, resulting in a noticeable improvement in decision-­making and performance [23]. As there are no objective means by which the competent practitioner can decide what goal, plan or perspective to take in any particular situation they must decide for themselves what choice to make, without any notion of whether their choice will be successful. This potential for making the wrong choice, with the attendant possibly of an adverse outcome, introduces an emotional element to the competent practitioner’s decision-making. If the outcome is successful, the link between that situation and goal, plan or perspective chosen is positively reinforced; a negative outcome will have the opposite effect. As a result of this, the competent practitioner feels

Proficiency

53

responsible for the outcome of their actions. In contrast, the novice and advanced beginner, who have been given rules and guidelines by their instructor to apply to elements of the situation to determine the correct action to take, blame the instructor’s poor selection of elements, rules and guidelines for failures, not themselves [24]. “A competent driver leaving the freeway on an off ramp curve learns to pay attention to the speed of the car, not whether to change gears. After taking into account speed, surface condition, criticality of time, etc., he may decide he is going too fast. He then has to decide whether to let up on the accelerator, remove his foot altogether, or step on the brake, and precisely when to perform any of these actions. He is relieved if he gets through the curve without mishap, and shaken if he begins to skid”. [25]

Goal → Plan → Perspective → Elements (Salience) → Rules and Guidelines → Actions If a situation, with its characteristic set of elements and saliences is encountered a number of times, it gradually comes to be recognised and is committed to memory. Dreyfus and Dreyfus call this mental representation of a specific real world situation a paradigm [26]. Initially a competent practitioner will see a number of paradigms and situations containing the same elements as similar, even if there are significant differences in the saliences of their elements. So a number of actual situations will be seen as similar to each individual paradigm [27]. As the competent practitioner gains more experience and learns to recognise subtle variations in the salience of the aspects and features characteristic of each specific situation, each existing paradigm will be replaced by a number of more refined paradigms. This process of refinement, with the generation of greater numbers of paradigms, will repeat itself until the elements and saliences of the individual paradigms come to accurately reflect the elements and saliences of the specific real-world situations they represent [28]. The transition to the two highest levels of skill, proficient practitioner and expert practitioner, involves the development of a qualitatively different kind of thought process that bears no resemblance to the thought processes characterised by the novice student, advanced beginner or the competent practitioner [29].

Proficiency The proficient practitioner having experienced many situations with their characteristic elements and saliences has gradually built-up a mental database of paradigms mapping to actual real-world situations. When a situation presents itself which is similar to a previously encountered situation, the relevant paradigm will present itself. The proficient practitioner does not have to work out what paradigm they are in. It is automatically retrieved from their mental database of paradigms and presented to them because of its similarity to the current situation. As elements of the situation and their saliences change, the current situation will stop resembling the

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current paradigm and will take on the characteristics of a closely related paradigm which is termed an exit paradigm [30]. The proficient practitioner having learnt what elements should be present in specific previously encountered situations will now begin to identify elements which would normally be present but are absent. These relevant negatives will be incorporated into the decision-making process [31]. As each situation may generate a number of possible actions, there are more potential actions than there are types of situations. So the proficient practitioner, while they may recognise intuitively what paradigm they are in, must then consciously examine the elements of that paradigm and their saliences to determine an appropriate action [32]. When deciding on the appropriate action to take the proficient practitioner utilizes maxims. Maxims, unlike guidelines or rules, reflect often miniscule variations in the salience of the elements of the situation that would not be recognised by the competent practitioner. The interpretation of the maxim and the action chosen will vary as the salience of the elements of the situation varies [33]. Maxims are based on explicit (as opposed to tacit) elements of the situation. They do not reflect the full extent of information the proficient practitioner uses to gain a true understanding of his current situation from a particular perspective with its own specific pattern of elements and saliences both explicit and tacit [34]. “The proficient driver, approaching a curve on a rainy day, may feel in the seat of his pants that he is going dangerously fast. He must then decide whether to apply brakes or merely to reduce pressure by some specific amount on the accelerator. Valuable time may be lost while making a decision, but the proficient driver is certainly more likely to negotiate the curve safely than the competent driver who spends additional time considering the speed, angle of bank, and felt gravitational forces, in order to decide whether the car’s speed is excessive”. [35]

The process of refining paradigms, which starts at the competent stage and results in an increasing number of paradigms which more accurately map to specific actual situations, continues through the proficient stage. As each paradigm is refined, the number of different actions suggested by specifying related different sets of elements and their saliences becomes gradually reduced. Likewise, the number of different sets of possible exit paradigms suggested by specifying different sets of elements and their saliences is gradually reduced. We may characterise the ability of the proficient practitioner as: [36]. • “The ability to remember a sizeable set of typical specific situations (paradigms). These memories, like most memories of situations are incomplete images, with gaps where details are irrelevant to the situation. • The ability to perceive the current situation as similar to one of those remembered paradigms. • The ability to notice when the current paradigm is no longer adequate for perceiving the current situation. • The ability to experience the current situation as similar to a different and more appropriate remembered paradigm, associated with each paradigm are

Two Additional Stages

55

various other exit paradigms which experience has taught are appropriate if the situation fails to fit the current paradigm in various ways”. This process sets the scene for the last stage in the refinement of the skill [37].

Expertise The expert practitioner, unlike the novice and advanced beginner and the competent and proficient practitioners, does not require a rule, guideline or maxim to determine the action to take in a specific situation. The expert automatically associates, without the need for conscious consideration, each paradigm with an appropriate action, which previous experience has shown to give a successful outcome to that situation. This level of attainment results from the expert having experienced a vast number of situations and the outcomes of a range of actions applied to each situation [38]. Eventually those paradigms requiring the same action become grouped together [39]. “The expert driver not only feels in the seat of his pants when speed is the issue; he knows how to perform the appropriate action without calculating and comparing alternatives. On the off-ramp, his foot simply lifts off the accelerator and applies the appropriate pressure to the brake. What must be done simply is done”. [40]

Dreyfus and Dreyfus note that: [41]. “When things are proceeding normally, experts don’t solve problems and don’t make decisions; they do what normally works”.

Two Additional Stages Mastery and Practical Wisdom Hubert Dreyfus subsequently described two additional stages, which were not a part of the original model: This involves developing a unique personal style. This almost always involves learning from acknowledged masters. But learning from one master produces imitators rather than creative individuals with their own style: [42]. “Working with several masters destabilises and confuses the apprentice so that he can no longer simply copy any one master’s style and so is forced to begin to develop a style of his own. In so doing he achieves the highest level of skill”.

Practical Wisdom [43]. “Not only do people have to acquire skills by imitating the style of experts in specific domains; they also have to acquire the style of their culture in order to gain what Aristotle calls practical wisdom. Children begin to learn to be experts in their culture’s practices from the moment they come into the world”.

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The Role of the Teacher in Skill Acquisition Dreyfus and Dreyfus consider that the role of the teacher in facilitating the acquisition of a skill by a student is to reduce the time for attaining a particular skill stage. Students develop their skills by an iterative trial and error process of trying out small random variations to their practice and reviewing the outcome. Variations leading to an improvement in performance are incorporated into the student’s practice; those not leading to improvement are rejected. A teacher can reduce the number of trial and error cycles taken to reach a particular level of attainment by directing the student to variations which are more likely to lead to an improvement in performance. Dreyfus and Dreyfus highlight the advantages of the apprenticeship model for achieving this end, particularly in professional schools [44]. In the absence of an apprenticeship model, Dreyfus and Dreyfus advocate that professional schools simulate the environment in which the student will eventually apply theory to practice in real-world professional practice [45]. Note that even with the best simulation it is not sufficient for the student to merely see and practice on a large number of cases. It is critical for attaining higher levels of skill (competent practitioner to expert practitioner) that there is an appropriate level of emotional engagement in the case [46]. While simulation can provide some degree of emotional engagement, the apprenticeship model provides a more effective method of achieving that aim [47]. This is so for professions requiring predominantly practical skills (e.g. motor mechanic) as it is for those requiring predominantly theoretical skills (e.g. mathematics). Guidance through apprenticeship by an experienced teacher in the real world environment will expose the student to those aspects of skilled behaviour which cannot be articulated as rules or guidelines in the classroom or simulation laboratory setting [48]. There is always the potential for a student or practitioner at one level to demonstrate the attributes of a student or practitioner at a higher level. However, their performance will be deficient, e.g. a novice student can appear to set goals like a competent practitioner but without an appreciation of the situation they are in, they will not set good goals [49]. A student or practitioner at a lower level of attainment observing a practitioner at a higher level of attainment will recognise a specific action in response to a specific situation. But due to lack of experience, it is likely to apply that action in response to a number of similar situations which can only be differentiated with experience. As a consequence, many of those situations will have a poor outcome [50].

Progression of the Components of the Dreyfus and Dreyfus Model The Dreyfus and Dreyfus model describes progression from an observer consciously analysing a situation for elements to apply to rules and guidelines to derive an appropriate action to a practitioner who subconsciously recognises situations as

Progression of the Components of the Dreyfus and Dreyfus Model

57

similar to previously experienced situations and applies actions based on previously successful actions in that situation [51]. The skill acquisition process described above results from the successive transformation of four cognitive processes. Each has a basic and an advanced form (see Table 7.1) [52]. Element recognition becomes situational when the student is able to identify elements of a situation as a result of previous concrete experience or by having them pointed out [55]. Salience recognition develops when the practitioner has taken responsibility for making a conscious choice of a goal, plan or perspective. Determining which element is salient in a particular situation depends on previous concrete experience combined with an awareness of recent events. It is experienced rather than consciously chosen [56]. Initially whole situation recognition is derived by combining component elements. It becomes holistic when the practitioner recognises his current situation as similar to a situation stored in his “database” of previous concrete experiences [57]. Finally, the “database” of whole situations is refined when each situation is linked to a previously successful action without the need for conscious thought [58]. Because they deal with explicit rules applied to context-free features novices know exactly what they know and how they know it. Experts on the other hand know what works, but cannot always explain why. Knowing how cannot be reduced to knowing that [59]. It should be noted that proficiency and expertise do not result from a more rapid execution of the rules, guidelines and maxims. It is only by dropping the rules that proficiency and expertise can be attained [60].

Table 7.1  Summary of the development of the five components of the skill acquisition model across the five stages of skill acquisition (modified from Dreyfus and Dreyfus) [53, 54] Skill Level

Element Recognition Salience Recognition Perspective Decision Commitment

Novice Context free (Non-­ situational) None None Rational (Analytical) Detached

Advanced Beginner Situational

Competent Situational

Proficient Situational

Expert Situational

None

Present

Present

Present

None Rational (Analytical) Detached

Chosen Rational (Analytical) Detached understanding and deciding. Involved in outcome

Holistic Rational (Analytical) Involved understanding Detached deciding

Holistic Intuitive (Analytical) Involved

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Summary In summary, the Dreyfus and Dreyfus model describes the successive stages of skill acquisition in unstructured situations. It is a situational (knowing how) rather than a trait (knowing that) model. The model describes how individuals progress from rule-based decision-making to experience-based decision-making. In the next chapter, we will consider the concept of competence in relation to skill acquisition.

References 1. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 19. 2. Benner P.  From novice to expert: excellence and power in clinical nursing practice. New Jersey: Prentice Hall; 2000. p. 13. 3. Dreyfus SE. A five-stage model of the mental activities involved in directed skill acquisition. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1980, p. 5. 4. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 20. 5. Ibid. 6. Ibid. 7. Ibid. p. 21. 8. Benner P.  From novice to expert: excellence and power in clinical nursing practice. New Jersey: Prentice Hall; 2000. p. 21–2. 9. Dreyfus SE. A five-stage model of the mental activities involved in directed skill acquisition. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1980, p. 7. 10. Dreyfus HL. On the internet: revised second edition. London and New York: Routledge; 2001, p. 27. From Dreyfus HL. On the Internet: Revised Second Edition. London and New York: Routledge; 2001, p. 27. Copyright © 2001, 2009 Hubert L Dreyfus, Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear. 11. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 22. 12. Dreyfus SE. A five-stage model of the mental activities involved in directed skill acquisition. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1980, p. 7. 13. Dreyfus HL.  On the internet: revised second edition. London and New  York: Routledge; 2001. p. 28. 14. Ibid. p. 15. 15. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 23. 16. Benner P.  From novice to expert: excellence and power in clinical nursing practice. New Jersey: Prentice Hall; 2000. p. 23. 17. Dreyfus SE, Dreyfus HL. The scope, limits and training implications of three models of aircraft pilot emergency response behavior. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Grant AFOSR-78-3594], University of California at Berkeley; February 1979, p. 7–8. 18. Dreyfus HL. On the internet: revised second edition. London and New York: Routledge; 2001, p. 29. From Dreyfus HL. On the Internet: Revised Second Edition. London and New York:

References

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Routledge; 2001, p. 27. Copyright © 2001, 2009 Hubert L Dreyfus, Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear. 19. Benner P.  From novice to expert: excellence and power in clinical nursing practice. New Jersey: Prentice Hall; 2000. p. 24–5. 20. Dreyfus SE.  The risks! and benefits? of risk-benefit analysis. Omega Int J Manage Sci. 1984;12(4):337. 21. Dreyfus SE.  Formal models vs human situational understanding: inherent limitations on the modeling of business expertise. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1981, p. 18. 22. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 24. 23. Dreyfus HL.  On the internet: revised second edition. London and New  York: Routledge; 2001. p. 30. 24. Dreyfus SE.  The risks! and benefits? of risk-benefit analysis. Omega Int J Manage Sci. 1984;12(4):337–8. 25. Dreyfus HL. On the internet: revised second edition. London and New York: Routledge; 2001, p. 31. From Dreyfus HL. On the Internet: Revised Second Edition. London and New York: Routledge; 2001, p. 27. Copyright © 2001, 2009 Hubert L Dreyfus, Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear. 26. Dreyfus SE, Dreyfus HL. The scope, limits and training implications of three models of aircraft pilot emergency response behavior. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Grant AFOSR-78-3594], University of California at Berkeley; February 1979, p. 3–5. 27. Ibid. p. 9. 28. Ibid. p. 9–10. 29. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 27. 30. Dreyfus SE.  Formal models vs human situational understanding: inherent limitations on the modeling of business expertise. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1981, p. 19–20. 31. Ibid. p. 20. 32. Dreyfus SE.  The risks! and benefits? of risk-benefit analysis. Omega Int J Manage Sci. 1984;12(4):339. 33. Benner P.  From novice to expert: excellence and power in clinical nursing practice. New Jersey: Prentice Hall; 2000. p. 29. 34. Dreyfus SE.  Formal models vs human situational understanding: inherent limitations on the modeling of business expertise. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1981, p. 20. 35. Dreyfus HL. On the internet: revised second edition. London and New York: Routledge; 2001, p. 35. From Dreyfus HL. On the Internet: Revised Second Edition. London and New York: Routledge; 2001, p. 27. Copyright © 2001, 2009 Hubert L Dreyfus, Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear. 36. Dreyfus SE, Dreyfus HL. The scope, limits and training implications of three models of aircraft pilot emergency response behavior. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Grant AFOSR-78-3594], University of California at Berkeley; February 1979. p 3–4. 37. Dreyfus SE, Dreyfus HL. The scope, limits and training implications of three models of aircraft pilot emergency response behavior. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Grant AFOSR-78-3594], University of California at Berkeley; February 1979, p. 9–10.

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38. Dreyfus SE.  Formal models vs human situational understanding: inherent limitations on the modeling of business expertise. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1981, p. 22. 39. Dreyfus HL.  On the internet: revised second edition. London and New  York: Routledge; 2001. p. 36. 40. Dreyfus HL. On the internet: revised second edition. London and New York: Routledge; 2001, p. 36. From Dreyfus HL. On the Internet: Revised Second Edition. London and New York: Routledge; 2001, p. 27. Copyright © 2001, 2009 Hubert L Dreyfus, Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear. 41. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 30–1. 42. Dreyfus HL. On the internet: revised second edition. London and New York: Routledge; 2001, p. 40. From Dreyfus HL. On the Internet: Revised Second Edition. London and New York: Routledge; 2001, p. 27. Copyright © 2001, 2009 Hubert L Dreyfus, Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear. 43. Ibid. p. 44. 44. Dreyfus HL. On the internet revised. 2nd ed. London and New York: Routledge; 2001. p. 37. 45. Ibid. 46. Ibid. p. 37–8. 47. Ibid. p. 38. 48. Ibid. 49. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 35. 50. Ibid. 51. Ibid. 52. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 50. 53. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 50. 54. Dreyfus SE. A five-stage model of the mental activities involved in directed skill acquisition. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley; February 1980, p. 15–16. 55. Dreyfus SE, Dreyfus HL.  February 1981. Formal models vs human situational understanding: inherent limits on the modelling of business expertise. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Contract F49620-79-C-0063), University of California at Berkeley. P. 25. 56. Ibid. 57. Ibid. 58. Ibid. p. 25–6. 59. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press; 1986. p. 30–1. 60. Benner P.  From novice to expert: excellence and power in clinical nursing practice. New Jersey: Prentice Hall; 2000. p. 37.

8

Competence

Competence is doing it right.

This definition, offered by my wife, would satisfy most medical practitioners and on that basis I would be tempted to close this chapter here. However, because the concept of competence has taken such a central position in modern medical education, training and clinical practice, I feel compelled to consider the matter further. The traditional approach to examining a subject such as competence is to review the literature. In relation to competence the body of literature is as wide as it is confusing. So rather than formally appraising the literature I will demonstrate the diversity of views on the nature of competence. The Concise English Dictionary defines competence as: [1] The quality or extent of being competent.

And competent as: “Having the necessary ability or knowledge to do something successfully.”

Eraut [2] provides a number of pertinent references which I will summarise here. He begins by discussing the seminal work “The Professions” by Carr-Saunders and Wilson (1933) [3] and notes that in the section “Professional Training and the Testing of Professional Competence,” [4] Carr-Saunders and Wilson made no attempt to define the term “competence”. Eraut further notes that: While their rationale of public assurance suggests a performance-based distinction between qualified and unqualified practitioners, the use of qualifying examinations suggests a distinction based on examinable knowledge. However, what seems like an inconsistency may not have appeared so to Carr-Saunders and Wilson, for whom the terms “competent” and “properly qualified” may have had almost the same meaning. Their attention was focussed on the transition from a concept of “professional” based only on social status to one based also on being properly qualified [5]. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_8

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Pearson [6] defines competence as being on a continuum between knowing how to do something and knowing how to do something very well. Messick [7] compares competence and performance in relation to school language examinations. He notes that competence relates to what can be done under ideal conditions and performance to what can be done under normal operational conditions. Messick comments that there are a host of other factors operating under normal operational conditions which may impact performance (e.g. affective, attentional, etc.) which are not necessarily present during the controlled environment of an examination. Gonzi [8] defines the observable as performance and what is inferred from that as competence. He notes that competence requires the individual to possess attributes such as knowledge, skills and attitudes but that some measure of successful performance is also required to complete the definition [9]. Looking more widely, White [10] proposed that competence is a psychological motivator for learning, distinct from drives and instincts. He defines it in terms of the effectiveness of an organism’s interaction with its environment. In relation to medical practice Newble defines clinical competence as “that which a student should be able to achieve at a given stage of their training” and clinical performance as “that which they actually achieve” [11]. Demonstrating competence requires that the individual exhibits adequate attainment in certain attributes including knowledge, skills and attitudes but demonstrating adequacy in these alone does not necessarily predict acceptable performance in the complex unpredictable real-world clinical environment. So, denoting an individual as competent implies that the individual is more likely to deliver adequate rather than expert professional performance.

Summary In summary, there is no clear consensus on the definition of the term competence in the literature. The literature tends towards defining competence in terms of an acceptable level of attainment in an assessment under non-­ operational conditions (e.g. an examination environment). This may provide some supporting evidence as to how an individual is likely to perform in the real-world clinical environment. The literature tends towards defining performance in terms of how an individual actually performs in the real world. In the next chapter we will discuss assessment and appraisal.

References 1. Concise Oxford English Dictionary, 11th edition (revised). Oxford: Oxford University Press; 2009. p.  292. From the Concise Oxford English Dictionary 11th edition (revised). Oxford: Oxford University Press; 2008. p. 292. © 2008. Reproduced with permission of the Licensor (Oxford Publishing Limited) through PLSclear.

References

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2. Eraut M.  Developing professional knowledge and competence. London: Falmer Press; 1994. p. 163. 3. Carr-Saunders AM, Wilson P. The professions. London: Frank Cass; 1964 (Originally published 1933). 4. Carr-Saunders AM, Wilson P.  The professions. London: Frank Cass; 1964, p.  307–318 (Originally published 1933). 5. Eraut M. Developing professional knowledge and competence. London: Falmer Press; 1994, p. 163. From Eraut M. Developing Professional Knowledge and Competence. London: Falmer Press; 1994 p.  163, © 1994. Falmer Press, Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear. 6. Pearson HT. Competence: a normative analysis, in Short EC (editor) Competence: inquiries into its meaning and Acquisition in Educational Settings. Lanham, MD: University Press of America; 1984, p. 32. 7. Messick S. The psychology of educational measurement. J Educ Meas. 1984;21:215–38. 8. Gonzi A, Hager P, Athanasou J.  The development of competency based strategies for the professions. National office of overseas skills recognition research paper no. 8. Canberra: Australian Government Publishing Service; 1993, p. 6. 9. Ibid. p. 5–6. 10. White RW. Motivation reconsidered the concept of competence. Psychol Rev. 1959;66:297–333. 11. Newble DI.  Assessing clinical competence at the undergraduate level. Medical Education. 1992;26: 504-511. From Newble DI.  Assessing Clinical Competence at the Undergraduate level. Medical Education. 1992;26:504–511. © 1996. Reprinted by permission of John Wiley and Sons, Publishers.

9

Assessment and Appraisal

I have given considerable thought as to whether I should include this chapter or not. On the one hand assessment and appraisal are so central to training and regulation in modern medicine that it would seem strange not to include them. On the other hand, the subject of assessment is well researched and is covered in detail in other books, and appraisal (at least for the UK) is adequately detailed in the publications from the General Medical Council (GMC) and National Health Service (NHS) England. I have, however, decided to include a brief overview for those readers who are not directly involved in either area on a regular basis. Jolly [1] defines assessment as “making interim or final judgments about people against defined, usually external, criteria”. Yorke [2] classifies the purposes of assessment into three broad categories: learning; certification and quality assurance. Yorke’s classification shows that assessment is used not only to judge students and their courses, but also to feedback to them on their progress, to aid their learning and to provide external assurance about the quality of the course/curriculum.

Types of Assessment Assessment is divided into formative and summative. Brown defines formative assessment as “a means of letting students know how they are doing and how they can improve” [3] and summative assessment as “classifying the level of achievements of students individually and comparatively within a cohort” [4] Miller defined formative assessment as a learning system and summative assessment as a certifying system [5]’ Although these two forms of assessment differ in their intent, it is possible to use similar assessment tools for both purposes.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_9

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What Should Be Assessed? Newble et al. [6] described three steps for defining what should be assessed: • Define the clinically desired level of resolution. • For each problem, define the clinical tasks at which students are expected to be competent. • Prepare a blueprint to guide the selection of problems to be included in the assessment procedure. In the case of medical staff, we would wish to ensure that they are competent not only in clinical skills but also in the communication and attitudinal skills appropriate to a practicing doctor. In defining these we can make use of both GMC guidelines and College curricula to draw up a list of skills and the level of attainment expected.

The Requirements of a Good Assessment Test Newble and Cannon [7] defined four requirements to determine whether a test is good: • • • •

Validity: Does it measure what it is supposed to measure? Reliability: Does it produce consistent results? Practicality: Is it practical in terms of time and resources? Positive impact on learning: Does it encourage the learner to learn what is required?

Poor sampling of course material in the assessment will inevitably lead to an unreliable test; an unreliable test cannot be valid. In designing an assessment, it is therefore essential to get the content right. There are methods to overcome or attenuate the effects of poor reliability, but these are only of benefit if the assessment has a high degree of content validity.

Norm, Criterion-Referenced and Ipsative Assessment Rowntree [8] defines criterion-referenced assessment as “judging the student against a pre-determined outcome” and norm-referenced assessment as “judging the student against the norm as determined by the performance of their peer group”. Medical examinations (both undergraduate and postgraduate) have traditionally been norm-referenced. Such an approach is the antithesis of modern educational practice and the trend now is to move towards criterion-referenced assessments [9]. There is a third assessment method termed an ipsative assessment which assesses an individual against their own prior performance [10].

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Types of Assessment There are a variety of assessment methods available, Newble and Cannon [11] describe nine categories with a number of subcategories: 1. Essay • Extended response • Restricted response 2. Short answer 3. Structured • Patient management problems (PMPs) • Modified essay questions (MEQs) 4. Objective tests • Multiple choice questions (MCQs) • Extended matching questions (EMQs) 5. Direct observation 6. Oral 7. Structured clinical/practical assessment • Objective structured clinical examination (OSCE) 8. Self-assessment 9. Learning portfolio Each assessment method has its own advantages and disadvantages. The choice of assessment method should be tailored to the specified objectives. Using a variety of assessment methods is one way of improving validity [12] .

The Blueprint To achieve a high degree of validity an assessment should provide a representative sample of the curriculum content and match each item with the optimum assessment method. The construction of a blueprint will aid in achieving this end. A blueprint in its simplest form consists of a list of competency characteristics to be tested cross referenced against a series of problems against which these characteristics are assessed [13].

Defensible Assessment Lew identified a class of performance assessment where the consequences were deemed to be “high stakes”. The results of such assessments may lead, for example, to remedial education, restricted license, or even removal of license. Lew stated that “these assessment programmes therefore need to be robust, fair and defensible” [14]. Lew described three broad areas to be addressed in setting up such a performance assessment framework (see Table 9.1): [15]

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Table 9.1  Areas to address in setting up a framework for performance assessment 1

2

1

2

3 4 5 6 1

Purposes and outcomes What are the purposes of the assessment? Whose purposes are being met? Are the purposes clearly stated and accessible prior to the implementation of the programme? What is the regulatory structure of the assessment and what are the possible outcomes and consequences of the decision? What does the assessor expect to learn from assessing the doctor’s performance? Planning the programme What steps were taken in planning the assessment programme to ensure its fairness and defensibility? Is the plan clearly described? Who are the assessees? Who are the assessors? How are the judgments determined? How have the assessors been chosen? How is the sampling done? Why were these instruments chosen? What is known about their technical characteristics? How is the standard set? Processes What steps were taken in the process of administering the assessment to ensure its fairness and defensibility? Communication and preparation of assessees Preparation of assessors Time allocations Equity and security Ability to appeal How are the assessees supported through the entire process? Cost

This framework can be used to judge the robustness, fairness and defensibility of both high and low stakes assessments. Clearly with formative assessment, which is a low stake assessment, the framework needs to be less rigorously adhered to and take into account time and cost constraints.

Miller’s Framework From the perspective of medical practice, if we mention the term assessment most practitioners will immediately think of Miller’s framework. Miller [16] described a framework for the assessment of clinical skills, competence and performance (see Fig. 9.1). In the first stage “Knows (Knowledge)”, Miller begins with seeking assurance that an individual has the basic knowledge required to undertake their professional duties to an acceptable standard [18]. In the second stage “Knows How (Competence)”, having acquired the basic knowledge, Miller seeks assurance that the individual knows how to apply the knowledge correctly in the clinical setting. This ranges from obtaining information from patients, laboratory and other diagnostic tests and reviewing and interpreting

Enhanced Appraisal

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Does (Action)

Shows How (Performance)

Knows How (Competence)

Knows (Knowledge)

Fig. 9.1  Miller’s framework [17]

them to arrive at a diagnosis and management plan. This is the level at which Miller defines competence [19]. In the third stage “Shows How (Performance)”, Miller seeks assurance that the individual can actually show how they would deliver in the clinical setting when confronted by a patient in a real-world situation [20]. For the first three stages Miller offers his views on the current state of assessment techniques for giving assurance and comes to the view that although not perfect, reasonable assurance can be gained from the techniques available at the time of his writing (1990). In terms of “Shows How” Miller goes into detail on the use of simulated patients to provide as close as possible an assessment as would happen in the real world [21]. In the final stage “Does (Action)”, Miller seeks assurance that what is assessed in the examination setting can be used to predict how individuals actually perform in practice when working independently [22]. Miller notes that at the time of writing (1990) much was still to be done to give assurance that what is assessed in the examination setting translates into what is delivered in clinical practice [23]. There remains, even now, 30 years on, a limited evidence base to support the predictive power of clinical assessments for future clinical performance [24] .

Enhanced Appraisal When I set out to write this chapter, the concept of revalidation was in the early stages of discussion. Consultant appraisal, a requirement of the 2003 consultant contract, was something of a hit and miss affair. With the introduction of revalidation in 2012, a process of enhanced appraisal was introduced. Appraisers providing enhanced appraisals are required to undertake formal enhanced appraisal training.

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To standardise the collection and collation of information for appraisal, a PDF-­ based form, the Medical appraisal guide (MAG) model appraisal form was developed by the NHS England Revalidation Support team [25]. The Medical Appraisal Guide: Model Appraisal Form (MAG Form) was updated in 2016 but the format remains essentially the same [26]. The core requirements for revalidation have been defined by the GMC in the Good Medical Practice Framework for appraisal and revalidation documents: [27] Four Domains each with three attributes: 1. Knowledge, skills and performance 3.1. Maintain your professional performance. 3.2. Apply knowledge and experience to practice. 3.3. Ensure that all documentation (including clinical records) formally recording your work is clear, accurate and legible. 2. Safety and quality 2.1. Contribute to and comply with systems to protect patients. 2.2. Respond to risks to safety. 2.3. Protect patients and colleagues from any risk posed by your health. 3. Communication, partnership and teamwork 3.1. Communicate effectively. 3.2. Work constructively with colleagues and delegate effectively. 3.3. Establish and maintain partnerships with patients. 4. Maintaining trust 4.1. Show respect for patients. 4.2. Treat patients and colleagues fairly and without discrimination. 4.3. Act with honesty and integrity. These domains and attributes map to specific paragraphs in Good Medical Practice, Leadership and Management for all doctors or Good Practice in Research. Doctors are required to keep a portfolio of supporting evidence to show that they are meeting the attributes in the framework. The framework is intended to be used to: • Reflect on your practice and your approach to medicine • Reflect on the supporting information you have gathered and what that information demonstrates about your practice • Identify areas of practice where you could make improvements or undertake further development • Demonstrate that you are up to date and fit to practise. The core requirements for completing the MAG form are: • A description of the full scope of the practitioner’s practice: this ensures that the appraisal considers the full scope of practice. • An annual record of completion of core continuing professional development (CPD) requirements (usually set by colleges and typically 50 hours of CPD:

Enhanced Appraisal

• • • • • • • • • •

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the GMC sets no absolute minimum). CPD to be mapped to the scope of professional practice over the revalidation cycle. Evidence of quality improvement activity, typically undertaking an audit once in a 5-year cycle with other quality improvement activities in between, e.g. guideline writing, attendance at governance meetings, etc. Agreeing a personal development plan and showing evidence of outcomes against the actions in subsequent appraisals. Structured colleague and patient feedback once every revalidation cycle (5 years). Underpinning this is the requirement to show evidence of reflection on the components of the appraisal process along with the signing off of a number of declarations: Involvement (or not) in significant events (with reflection) Involvement (or not) in complaints (with reflection) Declaration that the practitioner accepts the professional obligations placed on them in Good Medical Practice in relation to probity Declaration that the practitioner has (or not), been subject to suspensions, restrictions on practice or been subject to an investigation of any kind since their last appraisal Declaration that the practitioner accepts the professional obligations placed on them in Good Medical Practice about their personal health Complete the section reflecting on how the practitioner is meeting the requirements of Good Medical Practice in relation to the four Domains and three attributes in each domain

Following the appraisal, the appraiser is required to make a judgement against the following declarations to be submitted to the responsible officer and sign off relevant declarations: 1. An appraisal has taken place that reflects the whole of the doctor’s scope of work and addresses the principles and values set out in Good Medical Practice. Agree/Disagree 2. Appropriate supporting information has been presented in accordance with the Good Medical Practice Framework for appraisal and revalidation and this reflects the nature and scope of the doctor’s work. Agree/Disagree 3. A review that demonstrates progress against last year’s personal development plan has taken place. Agree Disagree 4. An agreement has been reached with the doctor about a new personal development plan and any associated actions for the coming year. Agree/Disagree 5. No information has been presented or discussed in the appraisal that raises a concern about the doctor’s fitness to practise. Agree/Disagree

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The final section of the form requires the practitioner and appraiser to make the following declarations: “I confirm that the information presented within this submission is an accurate record of the documentation provided and used in the appraisal”. “I understand that I must protect patients from risk of harm posed by another colleague’s conduct, performance or health. The safety of patients must come first at all times. If I have concerns that a colleague may not be fit to practise, I am aware that I must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary”. The responsible officer will use the information on the MAG form (over the revalidation cycle: typically, 5 years) to decide upon a recommendation to make to the GMC. That recommendation can be a recommendation to defer the practitioner for up to 1 year or to recommend revalidation. The responsible officer can also inform the GMC that the doctor is failing to engage with the appraisal process. It is important to note that it is the GMC that makes the final decision on revalidation based on the responsible officer’s submission.

Summary In summary, assessment and appraisal both involve coming to a judgement about an individual. Assessment involves coming to a judgement based on quantitative parameters. Appraisal involves coming to a judgement based on qualitative parameters (e.g. performance against agreed objectives or professional standards). Put simply, what we can measure we assess; what we cannot measure we appraise by setting objectives and monitoring progress in achieving those objectives. Either can be formative or summative and norm-­ referenced or criterion-referenced. Millers framework provides a model for conceptualising the assessment of clinical skills, competence and performance. The GMC enhance appraisal model provides a detailed account of an appraisal model for those in medical practice in the UK. In the next chapter we will consider the nature and structure of tacit knowledge.

References 1. Jolly B. Assessment and appraisal. Medical education. 1997;31(supp. 1): 20–24. From Jolly B. Assessment and appraisal. Medical Education. 1997;31(supp. 1): 20–24.; 2015, pp. 29–31. © 1997. Reprinted by permission of John Wiley and Sons, Publishers. 2. York M. Issues in the assessment of practice-based professional learning. A Report prepared for the Practice-based Professional Learning CETL at the Open University. https://www.academia.edu/24652668/Issues_in_the_assessment_of_practice-based_professional_learning (Accessed 25/03/2020) 3. Brown S, Race P, Smith B. 500 tips on assessment. London: Kogan Page;1996, p. 3. From Brown S, Race P, Smith B. 500 tips on assessment.; 1996, p.  3. © 1996. London: Kogan Page Ltd. Reproduced with permission of the Licensor (INFORMA UK LIMITED) through PLSclear.

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4. Ibid. p. 6. 5. Miller GE.  Continuous assessment. Medical education. 1976;10:81–86. From Miller GE. Continuous Assessment. Medical Education. 1976;10: 81–86. © 1976. Reprinted by permission of John Wiley and Sons, Publishers. 6. Newble D, Dawson B, Dauphinee D, Page G, Macdonald M, Swanson D, Mulholland H, Thomson A, Van der Vleuten C. Guidelines for assessing clinical competence. Teaching and Learning in Medicine. 1994;6(3):213–220. From Newble D, Dawson B, Dauphinee D, Page G, Macdonald M, Swanson D, Mulholland H, Thomson A, Van der Vleuten C.  Guidelines for assessing clinical competence. Teaching and Learning in Medicine. 1994;6(3): 213–220. Taylor and Francis. © 1994, reprinted by permission of the publisher (Taylor & Francis Ltd, http://www.tandfonline.com). 7. Newble D, Cannon R. A handbook for medical teachers (4th edn). London: Kluwer Academic; 2001. p. 128. 8. Rowntree D. Assessing students: how shall we know them? (Revised edn.). London: Kogan Page; 1987, p.  178. From Rowntree, D.  Assessing Students: How shall we know them? (Revised edn). 1987, p. 178. © 1987. London: Kogan Page, Reproduced with permission of the Licensor (Kogan Page Limited) through PLSclear. 9. https://www.aomrc.org.uk/wp-content/uploads/2016/05/Standard_setting_framework_postgrad_exams_1015.pdf (Accessed 25/03/2020) 10. Kolb DA. Experiential learning: experience as the source of learning and development. New Jersey: Prentice-Hall; 1984. p. 68. 11. Newble D, Cannon R. A handbook for medical teachers (4th edn.). London: Kluwer Academic Publishers; 2001, p. 134-158. 12. Ibid. p. 130. 13. Newble DI, Jaeger K. The effects of assessments and examinations on the learning of medical students. Medical Education 2003(May);17(3):165–71. 14. Lew SR, Page GG, Schuwirth LWT, Baron-Maldonado M, Lescop JMJ, Paget NS, Southgate LJ, Wade WB.  Procedures for establishing defensible programmes for assessing practice performance. Medical Education. 2002;36:936–941. From Lew SR, Page GG, Schuwirth LWT, Baron-Maldonado M, Lescop JMJ, Paget NS, Southgate LJ, Wade WB. Procedures for establishing defensible programmes for assessing practice performance. Medical Education. 2002,36:936–941. © 2002. Reprinted by permission of John Wiley and Sons, Publishers. 15. Ibid. 16. Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine. 1990(Sept);65(9):Suppl. S63–7. From Miller GE.  The Assessment of Clinical Skills/ Competence/Performance. Academic Medicine. 1990(Sept);65(9): suppl. S63–7. © 1990. Reprinted by permission Wolters Kluwer Health Inc., Publishers. 17. Ibid. 18. Ibid. 19. Ibid. 20. Ibid. 21. Ibid. 22. Ibid. 23. Ibid. 24. Terry R, Hing W, Orr R, Milne N.  Do coursework summative assessments predict clinical performance? A systematic review. BMC Medical Education. https://doi.org/10.1186/ s12909-017-0878-3 (Accessed 25/03/2020) 25. NHS England Revalidation Support Team MAG form: https://www.england.nhs.uk/medical-­ revalidation/appraisers/mag-mod/ (Accessed 25/03/2020) 26. NHS England Revalidation Support Team site: https://www.england.nhs.uk/medical-revalidation/ (Accessed 25/03/2020) 27. GMC The Good Medical Practice framework for appraisal and revalidation: http://www.gmcuk.org/static/documents/content/The_Good_medical_practice_framework_for_appraisal_ and_revalidation_-_DC5707.pdf (Accessed 25/03/2020)

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Further reading and GMC guidance https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation (Accessed 25/03/2020) https://www.england.nhs.uk/revalidation/ (Accessed 25/03/2020)

Tacit Knowledge

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Polanyi’s Model of Tacit Knowledge In discussing the structure of tacit knowledge we will start with the work of Michael Polanyi a philosopher and chemist. Polanyi begins by stating that: [1] “I shall reconsider human knowledge by starting from the fact that we can know more than we can tell. This fact seems obvious enough; but is not easy to say exactly what it means”.

Polanyi uses the term “tacit knowing” to describe this “knowing more than we can tell.” He demonstrates tacit knowing in relation to two examples, facial recognition and the use of a probe or stick to examine a dark cave. We recognise the face of an acquaintance in a crowd but cannot tell how we come to recognise it, i.e. we may know an individual's face without being able to define the particular features which lead to that recognition [2]. To explain this phenomenon Polanyi describes the structure of tacit knowing in relation to two terms: the proximal and the distal. The proximal term refers to the features which lead to our recognising the thing we know, in this example the characteristic facial features of an individual. The distal term refers to the meaning of those features, in this example the identity of the individual in question [3]. Polanyi then examines the use of a probe or stick to examine a dark cave where, unlike facial recognition, the proximal and distal terms are physically separated. When using a stick to probe the profile of a cave wall the impact of the stick against the cave wall can be felt as it is transmitted to the hand holding the stick. With experience the conscious sensation of the impact of the stick on the hand is transformed into an awareness of its point touching the cave wall. This separation of the body’s sensory appreciation of the impact of the stick on the hand from its physical meaning (the profile of the cave wall), is Polanyi’s justification for using the terms “proximal” and “distal” to describe the first and second terms of tacit knowing [4]. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_10

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The Comprehensive Entitiy

Those features which lead to our recognising the thing we know (e.g. an individual’s characteristic facial features)

Proximal Term

The meaning of those features (the identity of the individual)

Distal Term

Fig. 10.1  The relationship between the proximal term, distal term and comprehensive entity.

When proximal and distal terms are combined in an act of tacit knowing they cease to become individually recognisable, just as the ingredients of a cake cannot be distinguished once the cake is baked. Polanyi uses the term “comprehensive entity” to describe this integration (see Fig. 10.1) [5]. Polanyi describes the process of making something function as the proximal term of tacit knowing as indwelling or interiorization [6]. Iinteriorisation is similar to the concept of internalisation as discussed in Krathwohl’s taxonomy of the affective domain. Note that the features of a face and the sensation of the impact of the stick on the cave wall being transmitted to our hand only become proximal terms of a comprehensive entity when their recognition becomes tacit. Since we are not now aware of the features in isolation from the comprehensive entity which they jointly comprise, we cannot identify them. Polanyi proposes that if we regard the integration of features into the comprehensive entity as an interiorisation, then the process of interiorisation becomes the way in which we make something function as the proximal term of tacit knowing. Once interiorised we stop recognising them individually as themselves and only become aware of them as a part of the comprehensive entity which they jointly constitute with their meaning [7]. Polanyi describes how an unbridled lucidity can destroy our understanding of complex matters. If we try to closely examine the elements forming the proximal term of a comprehensive entity, their meaning is lost. There are numerous everyday examples of this. If we consciously repeat a word several times and concentrate our attention on the sounds we make and the movement of our mouth the word will rapidly come to sound strange and unfamiliar and will eventually lose its meaning. By concentrating attention on the features of the face of a friend or family member the face will rapidly come to seem odd and unfamiliar [8]. Polanyi then goes on to discuss in more detail the relationship between the two terms of the comprehensive entity and the impact of unbridled lucidity. Tacit knowing of a comprehensive entity relies on our tacit awareness of the features of the entity for us to be aware of their meaning. If we switch our attention to the features,

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this function of the features is cancelled and we lose sight of the meaning of the entity to which we had been attending [9].

Collins’ Taxonomy of Tacit Knowledge Harry Collins [10] an academic sociologist with an interest in the sociology of scientific knowledge, in his book “Tacit and Explicit Knowledge” seeks to clarify the concept of tacit knowing made famous by Michael Polanyi. Collins proposes a tripartite taxonomy of tacit knowledge [11]. • Relational tacit knowledge • Somatic tacit knowledge • Collective tacit knowledge He distinguishes, in his tripartite taxonomy, the kinds of knowledge that can (at least in principle) be made explicit from the kinds of knowledge that cannot. He draws a line between relational tacit knowledge and somatic tacit knowledge which can always, in principle, be made explicit, and collective tacit knowledge, which cannot [12]. He names them respectively weak, medium and strong tacit knowledge, the adjectives referring to the degree of resistance of the tacit knowledge to being made explicit [13]. We shall discuss them in order. Weak or Relational Tacit Knowledge (RTK): comprises knowledge that is tacit only because of contingent features relating to interpersonal interactions or attention. That is the knowledge is tacit for reasons that are not philosophically profound, but have to do with the relations between people arising out of the nature of social life. The reasons range from deliberate secrecy to failure to appreciate someone else’s needs. In principle, with enough effort, any piece of RTK could be rendered explicit. That not all of it can be rendered explicit at any one time has to do with logistics and the way societies are organised [14]. In a routine consultation for a blood pressure check during a busy surgery, a doctor may not recognise that the patient is attempting to open a conversation about an embarrassing condition such as erectile dysfunction. This knowledge could have been made explicit if the doctor had paid attention to the patient’s prompting questions (can the tablets affect me in any way?). If we consider the instance where a third party clinical assessor or a colleague is sitting in on the consultation, the assessor and patient will note the cue, but not the practitioner; this is the sense of relational tacit knowledge. Medium or Somatic Tacit Knowledge (STK) comprises knowledge that is tacit due to limitations of the human body and brain [15]. There are two subdivisions of somatic tacit knowledge: somatic limit and somatic affordance tacit knowledge. Somatic Limit Tacit Knowledge is knowledge that can be written out (at least in principle) but cannot be used by humans because of the limits of their bodies. In general machines of the right design can execute somatic limit tacit knowledge [17].

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Fig. 10.2  One of Meijaard’s equations for riding a bicycle

Meijaard et al. have described a series of complex equations for riding a bicycle (see Fig. 10.2 for one of the equations). These constitute somatic limit tacit knowledge because although they give the information required to ride a (very specific) bicycle, the time taken to calculate the required actions (a matter of minutes with a calculator) exceeds the time over which executing the actions would stop the bicycle falling over (milliseconds). In principle, if we were to ride the bicycle in a very low gravity setting, we would be able to calculate the actions and execute them before we fell over. On Earth it would, in principle, be possible to build a machine that could both calculate the actions and execute those actions before the bicycle falls over [16]. In this instance the “knowing that” is the equations, the “knowing how” is the riding of the bicycle without the use of the equations. We ride a bicycle tacitly not explicitly. Somatic Affordance Tacit Knowledge is knowledge that humans can execute only because of affordances (physical properties) of the substance of which they are made. In general, machines cannot execute somatic affordance tacit knowledge because they are not made of the right kinds of materials [18]. An affordance is a quality of an object, which allows an individual to perform an action, without which the action could not be performed. An example is the ability of humans to play chess. Although computers can now be programmed to best grand masters at chess, the computers win due to processing power. The human brain uses different analogue methods for playing chess. Strong or Collective Tacit Knowledge (CTK) comprises knowledge that is tacit because it depends on social and cultural judgements that depend on context and so cannot be generalised. Its acquisition relies on an individual being embedded in society. It is called strong because we know of no way to describe it or to make machines that can possess or even mimic it. CTK is a property of society rather than the individual [19]. Doctors, during a consultation will recognise when it is appropriate to have a chaperone and when it is not. Similarly, doctors will recognise when it is appropriate to discuss bad news with a patient and when it is not. The decision will vary with the patient and the circumstances. It would not be possible, even in principle, to derive an algorithm about how to make these decisions, which depend as much on the doctors’ own personality and cultural backgrounds as it does the patient’s.

Summary

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Relational Somatic

Collective

Fig. 10.3  Collin’s tripartite structure of tacit knowledge [20]

Summary In summary, Polanyi proposed the term tacit knowing for what Ryle calls “knowing how”. He proposes a structure for tacit knowing made up of a proximal term (features) that forms the basis for our recognition of a distal term (the meaning of the features). The two together comprise a comprehensive entity that exists only as long as we do not attempt to examine the features underlying it. Once we attempt to examine the elements of the proximal term it loses lucidity. Polanyi explains this in terms of the process of indwelling (interiorisation) of the features being the means by which they become the proximal term of the comprehensive entity. Once we surface the features they lose this function and the comprehensive entity no longer exists. Collins proposes a tripartite structure for tacit knowledge, weak, medium and strong, based on the degree to which each type can be made explicit (see Fig. 10.3). Relation Tacit Knowledge (Weak) is tacit due to the way in which individuals interact. Somatic Tacit Knowledge (Medium) is tacit due to the limitations of the human body and brain. Collective Tacit Knowledge (Strong) is tacit due to highly contextualised social and cultural elements that arise as a consequence of living within a particular society or culture. In the next chapter we will discuss theories of action and their place in defining the behavioural worlds we inhabit.

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References 1. Polanyi M. The tacit dimension. London: Routledge; 1967. 2. Ibid. p. 4–5. 3. Ibid. 4. Ibid. p. 12–13. 5. Ibid. 6. Ibid. p. 16–17. 7. Ibid. p. 17–18. 8. Ibid. p. 18–19. 9. Ibid. 10. Collins H.  Tacit and explicit knowledge. Chicago and London: The University of Chicago Press; 2010. 11. Ibid. p. 11. 12. Ibid. 13. Ibid. p. 85. 14. Ibid. p. 85–98. 15. Ibid. p. 99–117. 16. Meijaard JP, Papadopoulos JM, Ruina A, Schwab AL. Linearized dynamics equations for the balance and steer of a bicycle: a benchmark and review. Proc R Soc Lond A Math Phys Eng Sci. 2007;463(2084):1955–82. 17. Ibid. p. 102. 18. Collins H.  Tacit and explicit knowledge. Chicago and London: The University of Chicago Press; 2010. p. 109. 19. Ibid. p. 119–138. 20. Ibid. p. 158.

Theories of Action

11

Up until now we have been discussing events relating to, or derived from, the real world (except for a brief mention of the affective domain in relation to Krathwohl's taxonomy of the affective domain). It is generally agreed that we all inhabit a single objective world that exists independent of our conscious thought (i.e. take people out and it continues to exist). Constructivism holds that we each construct our own map of that world. This we do by the application of reason to the data we receive from our sense organs. This map consists of beliefs, some of which constitute true knowledge. In addition to the single conscious real world we all inhabit, we are each a part of numerous behavioural worlds. We are all part of specific behavioural worlds with our spouse and our children, individually and collectively, our work colleagues, etc. (see Fig. 11.1). Argyris and Schön hold that the behavioural worlds we inhabit are a product of our actions. They propose that thought and actions are integrated through theories of action [1]. “Theories of action are theories that can be expressed as follows: in situation S, if you intend consequence C, do A, given assumptions, a1, a2…..an [2].” This chapter summarises their work and thinking There are two types of theories of action: espoused theories of action (explicit: what I say I do) and theories-in-use (tacit: what I actually do). Our espoused theories and theories-in-use often differ but we are rarely aware of this difference [3]. As a consequence we rarely have insight into our actions with the result that we tend to justify them rather than critically examine and challenge them [4]. Making theories-in-use explicit and thereby open to reflection is the key to professional learning [5, 6].

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_11

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Behavioural World 3

Behavioural World 4

Behavioural World 1

Behavioural World 5

Behavioural World 2 Constructed Reality

REALITY Subjective beliefs

Objective beliefs

Fig. 11.1  Behavioural and real worlds

Governing Variables

Action Strategies

Consequences (Behavioural World)

Fig. 11.2  The structure of theories-in-use

The Structure of Theories-in-Use Argyris and Schön suggested a structure for theories-in-use involving three components (see Fig. 11.2) [7].

Governing Variables Governing variables (e.g. energy expended, anxiety, time spent with others) define what we want. Each has an acceptable operating range within which we strive to maintain them. Our field of constancy is defined as the core group of governing variables that must be kept in their acceptable range.

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Action Strategies Action strategies define the actions by which we keep our governing variables in their acceptable range.

Consequences All of our actions have consequences, both intended and unintended. The consequences of our actions define the specific behavioural world(s) we inhabit. When we want to achieve a certain goal we focus our attention on a specific governing variable (the foreground variable). While focusing on the foreground variable we must still keep our other variables (the background variables) within our field of constancy. Our governing variables are interrelated, so an action directed at the foreground variable may impact on a range of other background variables. Most actions impact on only a few governing variables, but certain core governing variables are involved in almost every action. This limits the actions we can take [8]. When we meet a new governing variable it may initially be outside of the acceptable range. If so it becomes our foreground variable and we focus on bringing it into its acceptable operating range. Once the new variable is brought into range it joins our field of constancy [9]. If our actions inadvertently move a core variable outside of its acceptable range this variable will become a foreground variable and we will concentrate our efforts on actions designed to move that variable back into its acceptable range [10].

Theories-in-Use Our theories-in-use define what we want and how we will get it [11]. They define the relationship between governing variables, their hierarchical order of importance in any given situation [12], their acceptable range and the actions required to keep them within that range [13]. Micro-theories are theories-in-use designed for use in specific routinely encountered situations. We have many micro-theories which are all interdependent [14]. Theories-in-use as well as defining the actions required to achieve a particular outcome in relation to a specific governing variable are also the means for maintaining our field of constancy [15]. As a consequence, theories-in-use are also important in their own right for the constancy of the world picture they provide [16]. The world we live in is highly complex with far more information available than we can cope with. So we simplify the world by producing models of particular aspects of the world which are defined by a manageable number of governing variables. The stability of these models depends on our theories-in-use defining the actions required to maintain the variables in their correct range. If the variables are in their correct range then the model will reflect the reality of the situation we have constructed [17]. Theories-in-use provide two orders of constancy: [18]

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1 . First-order constancy: maintaining governing variables within an acceptable range. 2. Second-order constancy: maintaining our current theory-in-use and by implication the constancy of our behavioural world. When our theories-in-use fail to maintain our core governing variables within their acceptable range we may consider changing our theories-in-use. But there is a strong imperative to keep our theories-in-use constant. In such instances therefore we may be forced to accept a compromise between maintaining first-order constancy (getting what we want in relation to a single variable) or maintaining second-­order constancy (maintaining the behavioural world we create). Ultimately in any single situation, we may choose not to get what we want in order to maintain a stable model [19]. Our theories-in-use are constantly evolving; such changes tending to be incremental, allowing equilibrium to be maintained by giving time for us to adapt to the associated changes. Sometimes, however, the changes are more dramatic and are initiated by what Argyris and Schön term dilemmas [20].

Dilemmas Dilemmas arise from conflicts between our governing variables, e.g. when attempts to keep one core variable in its acceptable range lead to another core variable moving outside of its acceptable range, or when conflicts between our espoused theories and our theories-in-use threaten the stability of our behavioural world. Ultimately we may have to choose between keeping our disparate governing variables within their normal range or keeping our behavioural world constant [21]. One means of avoiding dilemmas is to gain insight into our theories-in-use and reconcile any gross disparities between them and our espoused theories before a dilemma arises. The key to this is to understand how we respond to discrepancies.

Single- and Double-Loop Learning Our normal response to the movement of a governing variable outside of its acceptable range is to devise an action to return it to its acceptable range (maintaining first-order constancy). An alternative response may be to critically examine the governing variables themselves, and if necessary change them. Argyris and Schön term these two responses single-loop learning and double-loop learning, respectively (see Fig. 11.3) [22].

Model I and Model II Behaviour Argyris and Schön called the single-loop learning Model I behaviour and double-­ loop learning Model II behaviour and noted that single-loop learning inhibits double-­loop learning [23]. They found that almost all individuals exhibit Model I

Model I and Model II Behaviour

85 Double Loop

Governing Variables

Consequences

Action Strategies

Single Loop

Fig. 11.3  Single-loop and double-loop learning Double Loop Model Two

Governing Variables

Action Strategies

Consequences

Model One Single Loop

Fig. 11.4  Single-loop and double-loop learning and Model I and Model II behaviour (Argyris and Schön)

behaviour, but the majority, when asked, espoused Model II behaviour (see Fig. 11.4) [24].

Characteristics of Model I Behaviour The aim of Model I behaviour is to maintain the constancy of our governing variables and the behavioural worlds they create. As such Model I leads to often deeply

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Table 11.1  Model I theory-in-use characteristics [26] The governing Values of Model I are: • Achieve the purpose as the actor defines it • Win, do not lose • Suppress negative feelings • Emphasise rationality Primary Strategies are: • Control environment and task unilaterally • Protect self and others unilaterally Usually operationalised by: • Unillustrated attributions and evaluations, e.g. "You seem unmotivated" • Advocating courses of action which discourage inquiry, e.g. "Let us not talk about the past, that is over." • Treating ones' own views as obviously correct • Making covert attributions and evaluations • Face-saving moves such as leaving potentially embarrassing facts unstated Consequences include: • Defensive relationships • Low freedom of choice • Reduced production of valid information • Little public testing of ideas

rooted defensive routines. These can operate at individual, group and organisational levels (see Table 11.1) [25].

Characterisitics of Model II Behaviour The significant features of Model II include the ability to collect, collate and review data and make inferences from that data. It promotes a culture where theories are made explicit and tested by seeking the views of others in an open dialogue where public testing of ideas is seen as the norm rather than the imposition of one individual’s view of the situation (see Table 11.2) [27]. Argyris and Schön look to move people from a Model I orientation and practice which fosters single-loop learning to a Model II orientation and practice that fosters double-loop learning. Only by questioning and challenging governing variables is it possible to produce new action strategies that can address changing circumstances [29]. Recall however that single-loop thinking makes us effective in day-to-day life as it allows us to do with little thought “what works in practice”. Life would be exhausting if we had constantly to examine and re-examine our underlying assumptions. In reality we generally only do so when there is a problem or inconsistency [30].

Surmmary In summary, our behavioural worlds are defined by our actions which are themselves defined by our desire to keep our core governing variables within an acceptable range. Our thoughts and actions are integrated through theories

References

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Table 11.2  Model II theory-in-use characteristics [28] The governing values of Model II include: • Valid information • Free and informed choice • Internal commitment Strategies include: • Sharing control • Participation in design and implementation of action Operationalised by: • Attribution and evaluation illustrated with relatively directly observable data • Surfacing conflicting view • Encouraging public testing of evaluations Consequences should include: • Minimally defensive relationships • High freedom of choice • Increased likelihood of double-loop learning

of action. Theories of action comprise our theories-in-use; what we actually do and our espoused theories; what we believe we do. Because these two are often at variance there is a tendency for us to justify our actions rather than address them. Argyris and Schön proposed two models of behaviour to account for our actions. Model I behaviour which strives to maintain the current behavioural world using single-loop learning. Model II behaviour which strives to challenge our current behavioural world and where necessary change the governing variables within our field of constancy using double-loop learning. Argyris and Schön propose strategies to move people from Model I to Model II behaviour. Model I behaviour is the predominant human behaviour. In the next chapter we will discuss the nature of reflection.

References 1. Argyris C, Schön D. Theory in practice. Increasing professional effectiveness. San Francisco: Jossey-Bass; 1974, p. 3–4. From Argyris C, Schön D. Theory in Practice. Increasing professional effectiveness. San Francisco: Jossey-Bass; 1974, p. 3-4. © 1974. Reprinted by permission of John Wiley and Sons, Publishers 2. Ibid. p. 6. 3. Ibid. p. 6-7. 4. Ibid. p. xiii. 5. Ibid. p. xviii-xix. 6. Ibid. p. 14–15. 7. Ibid. p. 21. 8. Ibid. p. 15. 9. Ibid. p. 15-16. 10. Ibid. p. 16. 11. Ibid. p. 15. 12. Ibid. p. 8. 13. Ibid. p. 15. 14. Ibid. p. 8.

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15. Ibid. p. 15–16. 16. Ibid. p. 16–17. 17. Ibid. 18. Ibid. p. 17. From Argyris C, Schön D. Theory in Practice. Increasing professional effectiveness. San Francisco: Jossey-Bass; 1974, p.  3-4. © 1974. Reprinted by permission of John Wiley and Sons, Publishers 19. Ibid. 20. Ibid. p. 30. 21. Ibid. p. 30–34. 22. Ibid. p. 18–19. 23. Ibid. p. xv. 24. Ibid. p. xiii. 25. Ibid. p. 63–84. 26. Ibid. p. 68–69. From Argyris C, Schön D. Theory in Practice. Increasing professional effectiveness. San Francisco: Jossey-Bass; 1974, p. 3-4. © 1974. Reprinted by permission of John Wiley and Sons, Publishers 27. Ibid. p. 85–93. 28. Ibid. p. 87. From Argyris C, Schön D. Theory in Practice. Increasing professional effectiveness. San Francisco: Jossey-Bass; 1974, p.  3-4. © 1974. Reprinted by permission of John Wiley and Sons, Publishers 29. Ibid. p. xxii–xxiv. 30. Ibid. p. 19.

Reflection

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Reflection is a process of actively examining our actions and their outcomes to inform future actions. It would be difficult to begin any discussion about reflection without reference to the work of Donald Schőn [1]. Schőn has highlighted the central role of reflection in raising awareness of tacit knowledge in professional practice and transforming what he terms knowing in-action (Tacit) to knowledge in-action (Explicit). The key concepts that Schőn brings to our framework are those of reflection-in-action, reflection-on-action, the action present, framing, re-framing and the view that tacit knowledge is (at least in part) amenable to codification by the process of reflection. Schőn [2], like Oakshott [3], Ryle [4], and Polanyi [5] before him, begins by noting that when we perform the normal activities of our everyday personal or professional lives we are not, in general, consciously aware of what we are doing (e.g. we recognise a sick child at a glance without consciously recognising what it is that tells us the child is sick). When asked to describe how we conduct these activities, skills or functions we find it difficult or impossible to articulate a full description of them. In such circumstances what we know is tacit and is intimately bound up in our actions. Schőn describes this as our knowing being in our action (knowing in action). Schőn describes how there are many aspects of our daily lives such as psychomotor activities, recognition of objects and judgements which occur without conscious thought. Some we have had to learn them but for many we cannot recall having actively learned them [6].

Reflection-in-Action In general, as long as things are going according to plan we are rarely aware of the tacit knowing that underpins most of our activities and actions (think of driving to work in the morning); however, when things are not going to plan our attention may be drawn to the discrepancy (if you suddenly meet a traffic jam, you have to stop © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_12

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and consciously work out a detour). Schőn calls the conscious thinking derived from such discrepancies reflection-in-action and notes that reflection-in-action is usually initiated by the occurrence of the unexpected. In such cases, reflection-in-­ action tends to focus on our actions, the outcomes of our actions and the tacit knowing implicit in the actions [7].

Reflection on Action Partnered with the concept of reflection-in-action is the concept of reflection-on-­ action [8]. The key concept which differentiates the two is that of the action present. The action present is the time period during which an action can impact on the outcome of the situation. The action present may stretch over minutes (e.g. a cardiac arrest), hours, days, weeks and even months (e.g. diagnosing a difficult medical problem in the outpatient setting) depending on the rate of progress of the activity [9]. Reflection-in-action describes reflection which occurs in the action present when the reflection has the potential to enable actions which may impact on the outcome. Reflection-on-action describes reflection which occurs after the action present when an action has no ability to impact on the outcome (but reflection-on-action does have the potential to impact on future events): • Reflection-in-action (real time) • Reflection-on-action (post action) Schőn notes that professional practice involves professionals repeatedly encountering the same core of common situations characteristic of their practice. Over a period of time, as they experience a range of the varied presentations of these common conditions, they come to learn which diagnostic procedures and problem-­ solving techniques to apply to the management of which conditions. With experience the practitioner’s actions become increasingly tacit and unconscious. This brings benefit to the practitioner as less conscious effort is required to work out what situation they are in and what actions are required [10]. The narrowing of fields of professional practice (e.g. sub-specialisation in Medicine) while benefiting the specialist practitioner can lead to problems when the specialist encounters cases outside of their normal practice. In such situations, reflection can help the practitioner make sense of the new situation [11].

Framing When a practitioner finds themselves stuck in a situation which they cannot resolve, they may formulate a different view of the situation which they then try to impose on the problem. Schőn describes this as re-framing the situation (e.g. reconsidering the cause of a patient’s shortness of breath to be cardiac in origin rather than respiratory when they fail to respond to standard respiratory treatments) [12].

Framing

Reframe the Problem

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Reflect in Action

Test the Reframed Problem

Problematic Situation

Fig. 12.1  Diagram of the relationship between re-framing and reflection-in-action

Once the problem is reframed the next step is to try to fit the problem to the new frame and test the reframed problem using what Schőn terms a frame experiment (see Fig. 12.1) [13]. The frame experiment involves testing the reframed problem against some or all of the following criteria: [14] • • • •

Does the frame experiment give a desirable outcome (whether intended or not)? Does the outcome help solve the problem? Does the outcome add clarity to the problem-solving process? Does the outcome progress the problem-solving process towards a solution?

The re-framing of the problem presents a different perspective on the situation which may produce a solution, a partial solution, or at least move the problem-­ solving process forward. The reframed problem may not always produce a desired solution in which case the problem is reframed again. The problem-solving process is iterative and may involve several re-framings of the problem until a satisfactory outcome is achieved [15]. Re-framing of the problem may produce expected or unexpected outcomes that may produce intended or unintended consequences. There are four possible permutations which are described below and summarised in Table 12.1. • Unexpected and undesirable outcome: the re-framing process fails to produce the intended result and the consequences are considered undesirable. This initiates a process of reflection-in-action and the development of a new frame which itself is subjected to a frame experiment [17].

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Table 12.1  Expectations and outcomes of a framing experiment Expected Unexpected

Desirable/Neutral No requirement for Reflection-in-Action or a New Frame No requirement for Reflection-in-Action or a New Frame

Undesirable Reflection-in-Action and a New Frame required Reflection-in-Action and a New Frame required

• Unexpected but desirable or neutral outcome: the re-framing process fails to produce the intended result but the consequences are considered desirable or neutral. The re-framing, while not having delivered the intended result, delivers a result that may be acceptable as the consequences are desirable or neutral. The re-framing has moved the problem-solving process forward albeit not in the direction intended. There is no requirement for reflection-in-action [18]. • Expected and desirable or neutral outcome: the re-framing process produces the intended result and the consequences are considered to be desirable or neutral. There is no requirement for reflection-in-action [19]. • Expected but undesirable outcome: the re-framing produces the intended result but the unintended consequences are considered to be undesirable. This initiates a process of reflection-in-action in an attempt to mitigate the undesirable consequences while retaining the intended result [20]. It can be seen that in the professional domain reflection is a key part of the process of framing or re-framing a problem. Although Schőn is noted for his description of reflection, he provides no clear framework for the practitioner to actually use reflection in the course of their everyday professional life. There are a number of models of reflective practice available. I will briefly discuss three commonly used in the healthcare setting.

Gibbs (1988) Model of Reflection Gibbs described a model of reflection that is used widely within the health profession. Gibbs’ model is clear and structured and guides the practitioner through six stages of reflection to help them make sense of the situation which triggered the reflection. The model helps the practitioner to critically examine their practice and it also prompts them to develop an action plan to inform their response to similar situations in the future [21]. Description • Describe the event but do not analyse it yet. Feelings • Describe how the event made you feel but again do not analyse it yet.

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Evaluation • Describe the positive and negative aspects of the event as analysed against your own values. Analysis • Describe how do you see the event when looked at from different perspectives both personal and other peoples. Conclusions (general) • What is your general conclusion about what happened? Conclusions (specific) • What is your personal conclusion about what happened? Personal action plans • How would you handle the event in future? Gibb advocates moving logically from one stage to the next and clearly differentiating the transition from one to the next.

John’s Model of Reflection Johns’ Model22 provides a more in-depth structure to guide reflection. The model is divided into five sections: Aesthetics: • • • • •

What was I trying to achieve? Why did I respond as I did? What were the consequences of that for the patient, others and myself? How was the person feeling? (or these persons) How did I know this? Personal:

• How did I feel in this situation? • What internal factors were influencing me? Ethics

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• How did my actions match with my beliefs? • What factors made me act in incongruent ways? Empirics • What knowledge did or should have informed me? Reflexivity • How does this connect with previous experiences? • Could I handle this better in similar situations? • What would be the consequences of alternative actions for the patient, others and myself? • How do I now feel about the experience? • Can I support myself and others better as a consequence? • Has this changed my way of knowing?

A Third Model of Reflection A third, more generic model runs: • What? What happened? • So what: What does it mean? • Now what: What will I do about it? No model is superior to the other. Each practitioner should select one or more models that suit their personal style and modify them to fit their personal requirements and situation.

Summary In summary, reflection involves a conscious, structured review of an individual’s experiences, actions and the outcome of those actions with the intent of informing current and future actions and behaviour. Reflection may occur at the time the issue being reflected on is unfolding in the “action now” or subsequent to the action (reflection on action). This review process may be a one-off in response to a specific incident or issue or it may be an iterative part of a problem-solving process utilising framing, re-framing and frame experiments. Johns and Gibbs each describe models that are in common use in professional practice. In the next section I will synthesis the literature from this section as a prelude to describing a conceptual framework model for how doctors learn based on the work described in this book.

References

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References 1. Schőn D. The reflective practitioner: how professionals think in action. New York: Basic Books; 1983. 2. Schőn D. The reflective practitioner: how professionals think in Action. New  York: Basic Books; 1983, p. 49. 3. Oakeshott M. Rationalism in politics: and other essays. Indianapolis: Liberty Fund; 1991, p. 12. (First published 1962: London, Methuen), 4. Ryle G. On knowing how and knowing that.The concept of mind. London: Hutchison: 1940, p. 32. 5. Polanyi M. The tacit dimension, London: Routledge; 1967, p. 9. 6. Schőn D. The reflective practitioner: how professionals think in action. New  York: Basic Books; 1983, p. 54. 7. Ibid. p. 56. 8. Ibid. p. 61. 9. Ibid. p. 62. 10. Ibid. p. 60–61. 11. Ibid. p. 61. 12. Ibid. p. 63. 13. Ibid. p. 131. 14. Ibid. p. 133. 15. Ibid. p. 134–136. 16. Ibid. p. 153. 17. Ibid. 18. Ibid. p. 155. 19. Ibid. p. 156. 20. Ibid. 21. Gibbs G. Learning by doing: a guide to teaching and learning methods. Further Education Unit, Oxford Brookes University, Oxford; 1988; p. 49–50. 22. Johns C. Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. J Adv Nursing. 1995;22(2):226–234. From Johns C. Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing. 1995;22, 2: 226–234. © 1995. Reprinted by permission of John Wiley and Sons, Publishers.

Part II Synthesis

Overview to Synthesis

13

Before commencing on the synthesis of the literature reviewed in Section 1, I want to define the ontological and epistemological position I am starting from and also introduce some additional concepts not previously discussed which I will be using in this and the following Part.

Ontology and Epistemology As previously discussed there is one single objective reality that exists independent of conscious awareness. Take humans out of the universe and that objective reality continues to exist. If we now introduce a single human being into that reality they can only come to know about it through their senses (empiricism) or through their mind generated hypotheses (rationalism). If we introduce a second human being into that reality they can also only come to know about it and the first individual through empiricism and rationalism. When we come to experience a new aspect of reality (e.g. learning a new skill) we generally bring some prior experience to bear on our interpretation of that new aspect. As no two individuals will have the same prior experience we each construct our own interpretation of the new aspect which will differ from the interpretation of others experiencing the same aspect: this position is called constructivism. For certain specific objective aspects of reality (e.g. factual knowledge) all those experiencing that aspect will have the same interpretation: this position is called objectivism.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_13

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Hierarchy of Comprehensive Entities If we consider a particular aspect of behaviour, we can look at it on a number of levels. We can consider the molecular events which lead to the triggering of an action potential along a neuron and across a synapse, the interaction of the neurons in the network leading to the expression of the behaviour or to the actual behaviour itself. Each level is interrelated as ultimately all behaviour is derived from the initiation of action potentials. To understand how these different levels are related we will return to the work of Polanyi and his description of what he terms the hierarchy of comprehensive entities [1]. We will remind ourselves of the structure of a comprehensive entity (see Fig. 13.1). Recall that we come to know a comprehensive entity through a tacit awareness of the features (proximal term) which leads us to recognise explicitly the meaning of those features (distal term). Polanyi describes the proximal and distal terms of the comprehensive entity as two levels of reality each of which is controlled by different rules. The upper level relies upon the lower level for its existence. Polanyi explains this further in relation to the five levels involved in giving a speech, each of which has its own rules (see Table 13.1). Polanyi describes how the rules controlling a specific level of this hierarchy of comprehensive entities constrain the rules of the next level up (see Fig. 13.2). Our voice is constrained by the sounds we can make (phonetics). The range of words we can use is constrained by the available vocabulary. The construction of The Comprehensive Entitiy

Those features which lead to our recognising the thing we know (e.g. an individual’s characteristic facial features)

The meaning of those features (the identity of the individual)

Proximal Term

Distal Term

Fig. 13.1  Structure of a comprehensive entity Table 13.1 Successive levels of speech making

Level Voice Words Sentences Style Literary composition

Rules or principles governing the level Phonetics Vocabulary Grammar Stylistics Literary criticism

Hierarchy of Comprehensive Entities

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Literary Criticism Stylistics Grammar Vocabulary Phonetics

Fig. 13.2  Hierarchy of comprehensive entities

sentences is constrained by the rules of grammar. The grouping of sentences is constrained by the style of writing (e.g. poetry or prose) and the acceptable range of literary composition is constrained by the recognised structure of that literary style and the limits to which it is felt permissible to stretch them. Each level of the hierarchy is under two levels of control; by the rules governing the operation of one level and the rules governing the corresponding comprehensive entity. All the levels together comprise a succession of comprehensive entities (see Fig. 13.3). Polanyi then goes on to explain that knowledge of the functions of one level cannot be derived by understanding the rules of the lower level. We cannot construct the vocabulary of a language just by knowing the available speech sounds; but the vocabulary we can construct is constrained by the available speech sounds. We cannot derive the rules of grammar just by knowing the available vocabulary, but the possible rules of grammar are constrained by the available vocabulary. We can draw an analogy with the stacking of rimmed flowerpots (see Fig. 13.3). Each flower pot relies on the flower pot below to support it, but we cannot look over the rim of the flower pot below and see into the flower pot above. So by analogy we cannot know the rules of one level just by understanding the rules of the level below. Polanyi called this the principle of marginal control.

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Literary Criticism

Literary Criticism

Literary Criticism

Stylistics

Stylistics

Grammar

Grammar (Distal Term) Vocabulary (Proximal Term)

Stylistics (Distal Term) Grammar (Proximal Term) Vocabulary

Vocabulary (Distal Term) Phonetics (Proximal Term)

Phonetics

Phonetics

Literary Criticism (Distal Term) Stylistics (Proximal Term) Grammar Vocabulary Phonetics

Fig. 13.3  A succession of comprehensive entities

So while the lower level of a comprehensive entity cannot dictate the rules of the level above, it does constrain the options available to that level. Although we cannot construct the words of a language by merely knowing the sounds available in that language we also cannot construct words using sounds that do not exist in that language. So in general we can consider operations at a particular level of a hierarchy of comprehensive entities without necessarily being able to relate those operations to the structure of the level underlying the level we are considering—much as we can use a computer without necessarily knowing how it works. This structure of a succession of comprehensive entities and the principle of marginal control is important as it allows us to construct a model for how doctors think and learn without necessarily being able to map the particular components of the model to any specific neural pathway or to the firing or non-firing of an action potential in a specific neuron. The model will derive its value from its ability to explain a specific phenomenon we experience and not by whether it can be proven to be “true” by reference to specific physiological or anatomical elements.

Positivism For most of the twentieth century and into the twenty-first century the predominant philosophical theory underpinning medical education in the United Kingdom has been Positivism. Positivism recognises only knowledge which can be scientifically verified, is capable of logical proof or is capable of mathematical proof [2]. Wittgenstein, a leading proponent of positivism in the early part of the twentieth century stated that [3]: “What can be said at all can be said clearly, and what we cannot talk about we must pass over in silence”.

Wittgenstein’s statement is in direct conflict with Polanyi’s later view that [4]: “We know more than we can tell”.

The rise of positivism in the late nineteenth and early twentieth century led to a whole class of phenomena central to medical practice being at best unrecognised

Gestalt Psychology

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and at worst ignored (see box below). By the middle years of the twentieth century, few supported an exclusively positivist position, even Wittgenstein in his later works criticised his earlier work [5]. Bernstein in 1976 succinctly summarised the state of positivism when he stated that: “There is not a single major thesis advanced by either the nineteenth-century Positivists or the Vienna Circle [a group of philosophers active from 1922 to 1936 who promoted positivism] that has not been devastatingly criticised when measured by the Positivists’ own standards for philosophical argument” [6].

We need to be clear that rejecting the positivist view does not equate with the rejection of science or the scientific method which has brought major benefits to modern medicine. Positivism as a whole has been rejected as it fails to recognise as valid classes of human experience and knowledge other than those that are scientifically validated. Positivism in 1980s’ medical education

“Tell me about bonding?” Professor of Obstetrics and leading advocate of bonding at a final year medical student viva: Student “Can see it, can’t measure it, doesn’t exist.” Burke D. Final Year Obstetric Viva. Birmingham; 1982.

Dualism In simple terms dualism holds that the non-material mind and the material body are separate. The concept is usually ascribed to Rene Descarte (Cartesian dualism), although the concept can be traced back to Greek philosophy. The concept that the mind and body are somehow separate entities persists in modern medicine. I will take the position that the mind and body are fully integrated and can influence each other in a reciprocal manner. Actions derived from one will always impact on the other in a reciprocal manner. I will leave the question as to the existence or otherwise of a soul to other forums. From the perspective of this book I only recognise a fully integrated mind, brain and body [7, 8].

Gestalt Psychology The Gestalt psychologist Kurt Koffka stated that: “it has been said that the whole is more than the sum of the parts. It is more correct to say that the whole is something else than the sum of its parts….” [9]

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It is often stated that we recognise objects or figures by “Gestalt” with the suggestion that there is some form of imprinting of the whole image on our brains. I do not subscribe to that view and believe that our recognition is based on the, predominantly tacit, identification of a group or groups of characteristic features of the object which define it, e.g. we can recognise a chair as a chair because it has the characteristics of a chair (even if we find it difficult to articulate what differentiates a chair from a sofa or stool); we recognise a specific chair because it has some unique characteristics of that chair [10].

The Hermeneutic Cycle The hermeneutic cycle describes an iterative process of coming to a greater understanding of an entity by examining its parts. Examination of the parts gives greater clarity about the entity which in turn gives greater clarity about the parts [11]. The process originated in relation to biblical studies. Originally the Bible was taken to be the literal word of God and therefore to require no interpretation. A view gradually evolved that there were greater truths to be uncovered from the bible by close examination of its texts and interpreting them. Hence the cyclical process of examination of the texts would lead to a greater understanding of the Bible as a whole, which itself would lead to a greater understanding of the texts [12].

Conceptual Framework A conceptual framework is a mini-theory that links a number of concepts, models and frameworks to provide a single holistic view on a specified subject or field of enquiry, in this instance how doctors think and learn. We can imagine the framework as being a three-dimensional scaffold. If we use the scaffold as a framework to fix the various models we have discussed in Part 1, then we can link them to indicate similarities or associations between them. So we have seen that concepts such as Piaget’s Schemas, Eraut’s routinisations, and Dreyfus and Dreyfus’s plans, describe differing aspects of a common process, namely the transformation of thought to action, so these can be linked. As well as linking the models, the framework also allows us to link the different insights the different authors have made about their individual model. This gives us a deeper insight into the process underlying adjacent models on the framework than the individual authors have gained by considering only their single perspective. Similarly, we are then able to link grouped models to other individual or grouped concepts to give a more comprehensive and in-depth view of the field we are studying. As an example we are able to derive a deeper understanding of the structure of tacit knowledge by the method outlined above. But also to link the Dreyfus and Dreyfus model, tacit knowledge and reflection into a more complex whole which in

References

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itself gives us a deeper understanding of how these individual concepts are interrelated and contribute to describing how doctors learn.

Simple, Complicated and Complex [13] Simple: For patients with simple conditions the factors required to make a decision on management are obvious and can be fully articulated in a rule, guideline, protocol or algorithm. Follow the rule, guideline, protocol or algorithm and a good outcome is almost guaranteed, e.g. a patient admitted with acute asthma. Complicated: Patients with complicated conditions have several simple conditions which require a degree of coordination or specialised expertise. However, the actual individual conditions are simple to manage so if care is coordinated the outcome will, like that of a simple condition, be almost guaranteed. Let us consider an example of a patient with multiple traumas with airway obstruction, a tension pneumothorax and fractured femur. Each condition has a simple treatment algorithm but it is important to treat each condition in a specific order to ensure the best chance of survival. For trauma this coordination of care can be learnt in the Advanced Trauma Life Support course. Complex: For patients with complex conditions the individual conditions interact with one another to such a degree that the outcome of any intervention will have a degree of uncertainty about it. Complex groups of conditions cannot be resolved down to the management of one or more rules, guidelines, protocols or algorithms and even good coordination will not guarantee a good outcome. In the next chapter we will use a cognitive approach to develop a model for the structure of knowledge which gives insight into the origin and nature of tacit knowledge.

References 1. Polanyi M. The tacit dimension. London: Routledge; 1967. p. 29–52. 2. Levene L.  I think therefore i am: all the philosophy you need to know. London: Michael O’Mara Books 2010, p. 178. 3. Wittgenstein L.  Tractatus logico-philosophicus. London: Kegan Paul; 1922, preface. From Wittgenstein, L. Tractatus Logico-Philosophicus. preface, copyright © 1961, 1974. Routledge & Kegan Paul. Reproduced with permission of the Licensor (INFORMA UK Limited) through PLSclear. 4. Polanyi M. The tacit dimension. London: Routledge; 1967. p. 4. 5. https://plato.stanford.edu/entries/wittgenstein/#TranCritTrac (Accessed 25/03/2020). 6. Bernstein RJ.  The restructuring of social and political theory. New  York: Harcourt Brace Jovanovitch; 1976, p. 207. 7. https://plato.stanford.edu/entries/dualism/ (Accessed 24/02/2018). 8. Levene L.  I think therefore i am: all the philosophy you need to know. London: Michael O’Mara Books 2010, pp. 92–95.

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9. Koffka K. Principles of Gestalt psychology. London: Routledge; 1999, p. 176. From Koffka K.  Principles of Gestalt psychology, Routledge, London. 1999. p.  176. © 1935  K Koffka. Routledge reproduced with permission of the Licensor (INFORMA UK Limited) through PLSclear. 10. Rosch E. Human categorization. In: Warren N, editor. Advances in cross culture psychology, vol. 1. London: Academic Press; 1977. p. 1–72. 11. https://plato.stanford.edu/entries/hermeneutics/ (Accessed 25/03/2020). 12. http://www.oxfordbiblicalstudies.com/article/opr/t94/e865 (Accessed 25/03/2020). 13. https://www.researchgate.net/publication/265240426_Complicated_and_Complex_Systems_ What_Would_Successful_Reform_of_Medicare_Look_Like (Accessed 25/03/2020).

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Polanyi approached his analysis of tacit knowledge from a philosophical perspective; Collins from a sociological perspective. I have approached my analysis from a cognitive perspective as a jobbing clinician with a strongly positivist background. I will propose a structure for tacit knowledge that addresses some aspects of tacit knowledge not fully explained by either Collins’ or Polanyi’s models but otherwise complements their work. Before embarking on a description of the proposed structure for knowledge it is important to be clear about who the tacit knowledge is tacit in relation to. The medical consultation example for Collins Relational Tacit Knowledge shows a specific piece of knowledge may be tacit with respect to one individual but explicit with respect to another. For the purposes of my structure I will always be referring to tacit knowledge in relation to the individual in question, the “me”. It is also important to be clear that when we talk about the use of thought to generate action we are talking about the ability of “my” brain to drive the actions of “my” body directly and not via third party means (e.g. pharmacological interventions). I will start by suggesting, like Collins, that there are at least two sorts of tacit knowledge: 1 . That which is inherently tacit 2. That which is potentially codifiable, transmissible and reproducible The second type of tacit knowledge can potentially be uncovered in a number of ways. One is by providing a language to describe our experiences. As an example we have discussed a taxonomy to describe the different types of explicit knowledge and to describe the various cognitive processes which can be applied to that explicit knowledge to transform it from one type or subtype to another.

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Explicit Knowledge

Codifiable Tacit Knowledge

Tacit Knowledge

Fig. 14.1  Relationship between explicit knowledge, tacit knowledge and codifiable tacit knowledge

New knowledge

Cognitive process (remembering) →

Memory

→

Knowledge 1

Cognitive processes (thinking) →

Knowledge 2

It would appear reasonable to assume that we recognise these types of knowledge and cognitive processes and their interrelationship when we encounter them because we can describe them. Without the taxonomy we would not have the language or structure to describe them, except perhaps through vague awareness of their existence. Codifying tacit knowledge has the potential to surface at least some of it as explicit knowledge (see Fig. 14.1). There is a good analogy to be had with the characterisation of a new disease. In the initial stages we have only the vaguest idea that there is a new disease entity. Perhaps a subgroup of patients with a known disease appear to have a cluster of signs and/or symptoms which tend to make them stand out from the general group with the known disease. As we come to describe the features of the new entity it comes to have a better defined boundary. The act of describing the features of the disease gives more clarity to the characteristics of the disease. That greater clarity leads to a more refined description of the disease. This reciprocal cycle of more refined language leading to a more refined characterisation of the entity and a more refined characterisation of the entity leading to a more refined language eventually leads to an acceptance of the new disease as different from other diseases. This iterative process is called a hermeneutic cycle. Until we have characterised a new disease (i.e. defined its diagnostic criteria) we will not be able to diagnose it. In an analogous way we can apply a hermeneutic cyclical process to our body of tacit knowledge which should enable us to uncover at least some of that knowledge (see Fig. 14.2).

Cognitive Perspective on Tacit Knowledge We have discussed previously how the formation of new neural networks and the modification or removal of existing networks through changes in the number of dendrites, synapses and spines is the neurophysiological basis for memory and learning. This process of hardwiring of learning by the establishment of new

The Knowledge Dimension

Hepatitis A

Hepatitis B

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Hepatitis A

Non A, Non B Hepatitis

Hepatitis B

Non A, Non B Hepatitis

Hepatitis A

Hepatitis B

Non A, Non B, Non C Hepatitis

Hepatitis C

Fig. 14.2  Diagrammatic representation of the characterisation of a new disease

anatomical and physiological neural pathways is also the basis of internalisation (Krathwohl) and interiorisation (Polanyi). Short-term memory has significant limitations on the amount of information it can hold and process due to chunk capacity limits. Hence data in our short-term memory is only held for as long as it is required. As soon as it has fulfilled its purpose it is committed to long-term memory to make room for new data to be processed or it is lost (forgotten). Our short term memory is constantly undergoing a process of housekeeping in order to make the best use of its limited capacity. Our long-term memory on the other hand has vast capacity and can retain data or information for extended periods and in many cases for life. If we now, consider our previous discussions on the nature of tacit and explicit knowledge in the light of the processes underlying learning and memory and the properties of memory we can see that much that is strange about tacit knowledge can be explained and understood in terms of these processes and integrated into a model for the structure of knowledge. I will begin by describing my proposed structure for knowledge in terms of three dimensions: • The knowledge dimension • The source dimension • The utility or action dimension

The Knowledge Dimension There are four types of knowledge: 1. Explicit knowledge: this is knowledge that can be codified (recorded), transmitted (passed on to others) and the actions derived from it reproduced (with the appropriate skills). I will add in an additional criterion for defining explicit knowledge at this stage which is that it only exists within an individual’s

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Table 14.1  Summary of explicit knowledge Definition • Codifiable • Transmissible • Reproducible • Only exists in our conscious awareness

Structure Factual • Knowledge of terminology • Knowledge of specific details and elements Conceptual • Knowledge of classifications and categories • Knowledge of principles and generalisations • Knowledge of theories, models and structures Procedural • Knowledge of subject-specific skills and algorithms • Knowledge of subject-specific techniques and methods • Knowledge of criteria for determining when to use appropriate procedures Metacognitive • Strategic knowledge • Knowledge about cognitive tasks • Self-knowledge

c­ onscious awareness. The structure of explicit knowledge can be described in terms of the types of knowledge described by Bloom as modified by Krathwohl and Anderson (see Table 14.1). As explicit knowledge only exists in conscious awareness and conscious awareness resides in short-term memory, then due to short-term memory chunk capacity, there is very little explicit memory in existence at any one time. Short-­ term memory housekeeping means that there is a constant interchange between the explicit knowledge in short-term memory and knowledge in long-term memory. This interchange is usually so fast that we do not recognise that it is happening and so gain the view that we are predominantly operating in the conscious domain. 2. Internalised tacit knowledge: this is explicit knowledge that has been committed to long-term memory through the short-term memory housekeeping process. The degree of hardwiring of internalised knowledge depends, amongst other factors, on how much we use this knowledge. The hardwiring may be permanent or temporary. It should be emphasised that by definition all internalised knowledge was once explicit knowledge and that internalised tacit knowledge can be re-­ surfaced to conscious awareness to make it explicit again. 3. Subliminal tacit knowledge: this is knowledge that has been committed to long-­ term memory via one of two pathways: a. Accessory pathways that do not, at least initially, reach conscious awareness, e.g. the accessory visual pathways. The majority of sensory input enters the brain by pathways which bypass the conscious mind. It is probably true that some of this subliminal knowledge can be consciously surfaced to become explicit knowledge with appropriate techniques, e.g. hypnosis or cognitive interviewing technique. Some however is not amenable to surfacing.

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b. The standard neural pathways have the potential to access conscious awareness. Because of the large volume of sensory input data flowing into our brain and the limited capacity of our short-term memory to deal with it some of this data is assigned to memory without ever being consciously surfaced or is lost. Only a proportion of the subconscious information reaching our brain from our senses is consigned to our memory. This information is committed to memory either because it relates to prior knowledge we have acquired (e.g. bird watchers are more likely to have subliminal knowledge related to bird watching) or because it has a particularly strong impact (e.g. witnessing a crime in progress or a traffic accident). Again, at least some of this data has the potential to be surfaced to conscious awareness as explicit knowledge. Note that subliminal knowledge may be surfaced as explicit memory by techniques that bring it to conscious awareness but it cannot be re-surfaced as it has never previously been raised to conscious awareness. Internalised knowledge on the other hand maybe re-surfaced as it has been previously raised to conscious awareness, i.e. to be re-surfaced (made explicit) the knowledge would have to have been explicit previously. 4. Intrinsic tacit knowledge: this is knowledge such as that which describes the workings of the autonomic nervous system, which controls many aspects of the body’s functions but is not, even in principle, amenable to conscious control. This knowledge is so deeply hardwired as to hardly warrant the term knowledge. Intrinsic tacit knowledge can be likened to the Read-Only Memory (ROM) of computers. We can possess very detailed knowledge of how these systems work (see any standard textbook of physiology), but we cannot use this knowledge to influence them. Again to be clear about what we mean by this statement. Our conscious mind has no ability to directly influence the workings of the autonomic nervous system. There are however two circumstances in which we can indirectly influence it: a. Some systems have dual inputs. We can learn to exert conscious control over our bladder because the sphincter has a somatic nervous supply which we learn to control. A marksman learns or is taught how to reduce their heart rate temporarily by taking in a deep breath, which reduces intrathoracic pressure, increases venous return, increases right heart filling and delays the onset of the next contraction. They may not be aware of the physiological basis for this effect but nevertheless learns to use it. This is not, however, direct influence on the autonomic system as we are not effecting the changes by directly ­acting on the system, but only by utilising alternative pathways amenable to conscious control. b. By developing specific drugs (or taking naturally occurring chemicals) that can mimic the action of neurotransmitters within the autonomic nervous system. But again note that this is not direct action by our brains on the system, it involves the indirect development and administration of a drug. Even if we cannot exert any direct conscious control over our autonomic nervous system we can:

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Knowledge Dimension

Increasingly Tacit

Explicit (Knowledge) Internalised Subliminal Intrinsic (Knowing)

Fig. 14.3  Summary of the types of knowledge and their increasingly tacit nature

• Know almost all there is to know about its anatomy, physiology and the biochemistry of its neurotransmitters, etc., but none of this allows us to influence the system directly from our brain. Note that an individual who knows nothing of the autonomic nervous system still has a perfectly functioning system. • Experience consciously the changes brought about by the autonomic nervous system on our bodies (even if we do not know that it is the functioning of the autonomic nervous system that is bringing about the changes), I can experience palpitation of my heart and the cramps of an overactive small bowel. The types of knowledge and their increasingly tacit nature are summarised in Fig. 14.3 (Appendix 1 provides a model to better help understand the structure of knowledge).

The Source Dimension There are four sources of knowledge: 1. Communal (cf: the practical wisdom of Hubert Dreyfus and the Collective Tacit Knowledge of Harry Collins). This is the acquisition of knowledge by being a member of a particular community. We are all members of specific communities. I am a member of the English community, the medical community, the paediatric emergency medicine community, etc. Each community has its own specific knowledge base which can only be acquired by being a member of that community. Communal knowledge is acquired in a similar fashion to the development of expertise as described by the Dreyfus and Dreyfus model; that is by many hundreds or thousands of iterations of social encounters with varying outcomes. We only know the acceptable boundaries for behaviour within a particular community (not as hard and fast boundaries but as zones) by being a member of that community. There is little to be gained by sitting in a classroom and asking “what would I do in this situation?” or “what would I do in that situation?” as the fine nuances of any real-world situation depends on aspects and features which are tacitly acquired and may vary with time. The essential feature of the acquisition of this form of knowledge is the exposure to concrete real-world experiences and situational awareness.

The Utility or Action Dimension

Source Dimension

113

Increasingly Personal

Communal (Collective) Ostensive Empirical Intrinsic

Fig. 14.4  Summary of the sources of knowledge and their increasingly personal nature

2 . Ostensive. Pointed out by others: “this is a melanoma” [1]. 3. Empirical. Derived directly from our sense experience. 4. Rational. Derived from the application of our own reason. As we descend down the domain the source becomes more personal to us. It is likely that there is overlap between different sources, e.g. the communal source will inevitably have input from the ostensive, empirical and rational. It would however be impossible to fully explain the ability to function correctly in a community by reference to knowledge derived from the last three sources alone because as noted above the ability to function in a community depends on many hundreds or thousands of individual concrete experiences with varying outcomes. Much of the knowledge that “tells” us tacitly how to behave in such situations is internalised and subliminal so is not fully amenable to explicit articulation. The sources of knowledge and their increasingly personal nature are summarised in Fig. 14.4.

The Utility or Action Dimension When considering the possible outcomes that can be achieved by actioning a particular piece of knowledge we need to consider the relationship between knowledge and action. Schön talks of the “action present”, the zone of time in which action can still make a difference to the situation. The action present may stretch over minutes, hours, days or even weeks or months. In the case of riding a bicycle (see tacit knowledge chapter) the action present is measured in milliseconds, in the case of an operation it may be hours; in the case of the management of a chronic medical condition it may be many years. There are three possible utility or actionable outcomes: 1. Actionable in the action now: The knowledge can be used to influence action in real time. A doctor in the resuscitation room can apply his knowledge of the current resuscitation guidelines to the management of a cardiac arrest. 2. Actionable but not in the action now: The knowledge could be used to influence action but not in real time. The bicycle equation detailed in Chap. 10 is an exam-

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ple of knowledge that can influence action, but not in the action present, at least for human beings. This is a fea‑ture of Collins’ somatic limit tacit knowledge. 3. Not actionable: The knowledge cannot be used to influence action (e.g. intrinsic knowledge). My detailed knowledge of the anatomy and physiology of the autonomic system does not allow me to control my autonomic system with my conscious mind. The ability of knowledge to influence action is summarised in Fig. 14.5. We can bring the three together to get an overview of the structure of knowledge (see Table 14.2 and Fig. 14.6). Action Dimension (Reflection)

Increasingly Actionable

Not actionable Actionable but not in the action now Actionable in the action now

Fig. 14.5  Summary of the ability of knowledge to influence action

Table 14.2  The knowledge and source domains Type of knowledge

Source of knowledge Rational Empirical

Ostensive

Communal

Explicit Internalised Subliminal Intrinsic

Actionable in the Action Now Source of Knowledge Rational

Empirical

Type of Knowledge

Explicit

Ostensive

Communal

Actionable but not in the Action Now

Internalised

Source of Knowledge

Subliminal

Rational Explicit Type of Knowledge

Intrinsic

Empirical

Ostensive

Communal

Not Actionable

Internalised

Source of Knowledge

Subliminal

Rational Explicit Type of Knowledge

Intrinsic

Internalised Subliminal Intrinsic

Fig. 14.6  The knowledge, source and utility domains

Empirical

Ostensive

Communal

Hardwiring and Tacit and Explicit Knowledge

115

Hardwiring and Tacit and Explicit Knowledge So the conscious processing of explicit knowledge is restricted by the limited capacity of short-term memory (conscious awareness); conscious processing of information is at a premium. Internalisation of explicit knowledge is part of the normal “housekeeping” of the brain, which reserves the limited capacity of our conscious awareness for only those tasks which absolutely require it. When I learn a specific psychomotor skill, such as balancing on one leg, at first I have to make conscious and crude corrections to my posture in order to stay upright. As the skill becomes hardwired, the subliminal and intrinsic pathways (e.g. proprioception) connect with the hardwired “learned” pathway and allow the corrections to be carried out, mostly, without conscious thought with the benefit that the skill is executed in a faster and more fluid manner without the need for conscious intervention. The parts of the brain dealing with the various forms of tacit knowledge (internalised, subliminal and intrinsic) are capable of multitasking. Note how, despite the lack of conscious thought, we manage to stay upright when running upstairs and alive when sleeping. So even though not all knowledge can be made explicit, it can all be included in tacit knowing in action, e.g. when you act tacitly everything connects automatically: • Running upstairs • Driving a car When you act explicitly, only the information you can bring to the conscious level can be used, i.e. when we make it explicit we lose the tacit connections. We can see then in moving up the Dreyfus and Dreyfus hierarchy that increasing concrete experience leads to increasing hardwiring of pathways, the recruitment of internalised, subliminal and intrinsic pathways, reduction in the conscious effort required to act and as a consequence an increased fluidity and speed of action. This division of knowledge into explicit (conscious) and tacit (subconscious) and the concepts of “hardwiring” and recruitment of tacit pathways explains Polanyi’s assertion that: “An unbridled lucidity can destroy our understanding of complex matters. Scrutinize closely the particulars of a comprehensive entity and their meaning is effaced, our conception of the entity is destroyed” [1].

As we internalise our explicit knowledge the new neural pathway we have formed interacts with internalised, subliminal and intrinsic pathways such that the amount of information available to, for instance, recognise a face is increased vastly beyond that available to the conscious awareness which deals only with explicit knowledge. If we now try to consciously deconstruct the process by which we came to recognise the face we have access to only the explicit component of that information. The explicit features seem flat or two dimensional. An analogy would be to

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look at a 3D colour film on a 2D black and white television. There is a wealth of additional information available; much of it cannot be accessed in that mode. Ordinarily conscious awareness cannot access the wealth of tacit knowledge available to the subconscious mind. It is only because internalised knowledge and explicit knowledge can be swapped rapidly (from our perspective virtually instantaneously) that we gain the impression that our explicit thinking is continuous. A good analogy is a film. It consists (in a traditional celluloid film reel) of individual frames which only have the appearance of movement because the frames are swapped so rapidly. If we consider these two pictures it will help to explain the phenomenon (Picture 14.1). In the first picture we have all of the information available to make a decision on the identity of the subject in an analogous way to our tacit recognition. In the second picture much of the information is not available in an analogous way to our explicit recognition. This also explains Polanyi’s structure of the comprehensive entity (see Fig. 14.7). The proximal term describes the information we use to recognise the entity in question (e.g. the face of a friend). The distal term describes the meaning of those features (e.g. the identity of the friend). Since much of the information used to recognise the face of a friend is tacit, we can only recognise them as long as we do not try to examine the features. As soon as we try to examine the individual features we flip into conscious thought mode and only have access to explicit features and lose access to the tacit features. The face looks strange. By consciously trying to

Tacit

Explicit

Picture 14.1  Pictorial representation of explicit and tacit knowledge

Hardwiring and Tacit and Explicit Knowledge

117

The Comprehensive Entitiy

Those features which lead to our recognising the thing we know (e.g. an individul’s characteristic facial features)

The meaning of those features (the identity of the individual)

Proximal Team

Distal Term

Fig. 14.7  The relationship between the proximal term, distal term and comprehensive entity

Conscious

Explicit

Subliminal

Internalised

Intrinsic Subconscious

Fig. 14.8  The four types of knowledge

examine the features we have vastly reduced the amount of information available with which to make the identification. If we consider the structure of an iceberg as an analogy for the hierarchy of tacit knowledge it perhaps brings a little clarity to the matter. We can see that the tip of the iceberg, representing explicit knowledge, is in the conscious domain, but comprises only a small proportion of the knowledge spectrum. Internalised knowledge is derived from explicit knowledge, but it inhabits the tacit domain, although it is capable of being re-surfaced when needed. The amount of knowledge and duration

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for which it can be re-surfaced being dependent only on the capacity of the conscious mind (see Fig. 14.8). In our ordinary everyday conscious existence, the vast ocean of tacit knowledge comprising internalised, subliminal and intrinsic knowledge is not evident to us. So we come to view explicit knowledge as the only valid form of knowledge. In this sense we can say that the tacit knowledge is the ordinary everyday knowledge available to us with explicit knowledge being an esoteric form of knowledge inhabiting only the conscious domain. Most of our daily activity, from the maintenance of our vital functions, the (usual) journey to work and the fine nuances of our professional practice happen only because of the existence of our tacit knowledge base.

A Note on Tacit Knowing and Tacit Knowledge Collins has been criticised for the use of the term tacit knowledge where Polanyi describes tacit knowing. This is to extent semantics, but it may be helpful here to give my view on the matter. We have seen that there are at least three meanings to the word knowledge: • A formal definition of a “(properly) justified true belief” • A less formal and looser use of knowledge to describe any belief • A wider use of the term to include “knowledge” of skills Up to now, I have used the term rather loosely. I would formally reserve the use of the term knowledge (whether of the formal type or not) for what we know explicitly in the conscious domain but include with that internalised knowledge. The term knowing, I would reserve for the subconscious classes subliminal and intrinsic and any actions we execute which have input from tacit pathways. It is arguable whether the intrinsic is tacit knowing or not, here it is included as it contributes to other hardwired pathways.

Summary In summary, Knowledge has a structure defined by three dimensions: the knowledge dimension, the source dimension and the utility or action dimension. The knowledge dimension comprises two types of knowledge, explicit and tacit with three subtypes of tacit knowledge. Explicit knowledge is codifiable, transmissible and reproducible and only exists in the conscious domain. It has a structure that can be defined using the knowledge classes described by Bloom or the knowledge types described by Anderson and Krathwohl. Tacit knowledge arises due to the limited capacity of short-term memory to retain data and only exists in the subconscious domain. There are three subtypes of tacit knowledge. Internalised knowledge is explicit knowledge committed to long-term memory. Subliminal knowledge is data from sensory organs that has by-passed

Reference

119

conscious processing and is committed to long-term memory and intrinsic knowledge is the information used to inform the working of the body. The source dimension comprises four sources of knowledge. Communal (collective) knowledge is derived from living within a particular group or community. Ostensive knowledge is derived by others “pointing out” what is. Empirical knowledge is derived from our sense experience and rational knowledge is derived by our brain processing data or information. The action (or utility) dimension defines the three possible outcomes from the knowledge we have. Not actionable, the knowledge cannot be used to influence outcomes, e.g. intrinsic knowledge cannot be used to directly influence the workings of the body. Actionable but not in the action now, the knowledge can be used to influence outcomes but not within the timescale where it will impact on events and actionable in the action now where the knowledge can directly impact on outcomes and change the course of events. When we think consciously we cannot access the vast resources of our subliminal and intrinsic tacit knowledge and can only access that portion of our internalised which can fit into the limited chunk capacity of our short-­ term memory. In the next chapter we will consider the nature and structure of skill and how an understanding of that refines the concept of competence and the structure of assessment.

Reference 1. Polanyi M. The tacit dimension. London: Routledge; 1967. p. 18–9.

Skill, Competence and Assessment Revisited

15

Skill We commonly use the term skill to describe a specific psychomotor ability (e.g. cannulation) or a specific cognitive ability (e.g. solving a crossword puzzle). For our purpose I would like to propose a broader definition of skill as: The ability to manipulate the environment to achieve a defined goal. In order to manipulate the environment, we need to: 1. Know what we want to achieve: i.e. (know the desired future state of the environment): set a goal. 2. Know the current state of the environment: take a perspective on the current situation. 3. Define the specific components of the current state that we need to change to achieve our goal: identify the elements of the current situation that are relevant to achieving the goal. 4. Decide on how to move from the current state to the desired future state: develop a plan with specific actions. 5. Implement the actions. 6. Have a system for reviewing progress against the plan: are the outcomes of the actions as expected? 7. Have a system for modifying the plan or actions if the current plan or actions are not achieving the desired outcome and therefore not moving us towards the goal.

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Skill Set We work in many environments on a day-to-day basis; a surgeon will work in the outpatient environment, the ward environment and the theatre environment etc. They will also work in more abstract environments such as the communicating bad news environment. Such environments (both concrete and abstract) can be subdivided into specific task environments, e.g. for the surgeon there will be the diagnostic task environment, the suturing task environment and the stapling task environment. Working within a particular environment requires the acquisition of the specific skills necessary to manipulate that environment. The traditional triumvirate of: • Knowledge • Skills • Attitudes/abilities suggests that these individual attributes can be considered in isolation from one another and indeed at the Dreyfus and Dreyfus novice and advanced beginner levels these attributes can be recognised and assessed individually. However, as individuals advance through the stages of competence, proficiency and expertise they migrate away from the concept of a skill being merely the psychomotor or cognitive component of performance. It is clear that a more sophisticated description of the structure of professional skill is required to adequately describe performance at the higher levels. I propose a model comprising a core of knowledge (tacit underlying explicit) with a wrapping of cognitive, affective and psychomotor domains. The precise proportions of each depending on the particular skill and the stage of development of that skill. By considering the structure of skill in this way we can see that any specific skill has a unique combination of attributes within the cognitive, affective and psychomotor domains along with a proportion of explicit and tacit knowledge. The structure further shows that there is overlap and interaction at the boundaries of the cognitive, affective and psychomotor domains, and that each domain has an interaction with the knowledge base. I will term this structure a skill set (see Fig. 15.1). It is important to understand the relationship between skill and skill sets. Skill is the generic ability to manipulate the environment to achieve a defined goal. A skill set describes the structure of an individual skill we use to achieve a specific goal. Skill sets are the enablers and more than one may be required to achieve any one goal. We can extend our understanding of the structure of a skill set further, by considering how the skill set develops as the individual progresses up the skill ladder. As the individual increases in experience the components of the skill set become progressively merged. The fundamental process underlying this merging of the individual components is internalisation, which results in the development of an increasing body of tacit knowledge.

Skill Set

123

PSYCHOMOTOR

EXPLICIT

TACIT

COGNITIVE

AFFECTIVE

Fig. 15.1  Proposed structure of a skill set

PSYCHOMOTOR

EXPLICIT

COGNITIVE

AFFECTIVE

COGNITIVE

PSYCHOMOTOR

PSYCHOMOTOR

PSYCHOMOTOR

EXPLICIT

EXPLICIT

EXPLICIT

o TACIT

TACIT

AFFECTIVE

COGNITIVE

TACIT

AFFECTIVE

COGNITIVE

TACIT

AFFECTIVE

Novice

Advanced Beginner

Competent

Proficient

Expert

Skill Set Rule

Skill Set Guideline

Skill Set Guideline

Skill Set Maxim

Complex Skill Set

Increasing level of internalisation

→

Fig. 15.2  Evolution of a skill set to a complex skill set

Finally, we reach the stage where the skill set is fully internalised at which point we can describe it as a complex skill set. At this stage we find it difficult or impossible to disassemble the components of the complex skill set into its component parts. Partly because they are so interrelated and partly because a significant part of the complex skill set relies on tacit pathways which we cannot ordinarily access through our conscious thought processes (see Fig. 15.2). The development and refining of skills can thus be described in terms of an ascent up the hierarchy of the Taxonomies of the three Domains of learning, the acquisition of more abstract cognitive processes, their application to more abstract

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Affective Cognitive

PSYCHOMOTOR

Psychomotor Cognitive Cognitive Affective Psychomotor Psychomotor

EXPLICIT

COGNITIVE

AFFECTIVE

Skill Set

Action and Competency

Fig. 15.3  Two alternate diagammatic represetnations of a skill set, action and competency

knowledge and the growth of a body of tacit knowledge through the process of internalisation by hardwiring. This process results in the development of complex skill sets which are a tacit combination of the three domains and associated knowledge which are not resolvable into their individual components. We may therefore say that it is the acquisition and development of skill sets to the level of competence that sets the scene for their refinement to complex skill sets that characterise the attainment of true professional status. Note the concordance between a skill set, an action and a competency. All consist of combinations of elements of the three domains of learning underpinned by a body of knowledge. The model for a skill set and model for an action can be used to diagrammatically illustrate them in two different ways (Fig. 15.3).

Piaget’s Schema’s Revisited In relation to our dealing with discrepancies between our current model for action which is based on the information we have about reality and new information which is at variance with that, Piaget described the achievement of equilibrium by the process of adaption. Adaption consists of the process of assimilation; fitting our existing schema to the new information and accommodation; the process of fitting our new information into our existing schema. A schema will consist of one or a series of skill sets or actions depending on how complex it is (see Fig. 15.4). For postgraduate learners we may add an additional term “abstention” to Piaget’s model to denote the circumstance in which an individual, in the face of overwhelming evidence, declines to change their schema. This may occur, for instance, when a trainee starts in a new unit and finds it difficult to adopt the guidelines and protocols of that unit over those of their previous workplaces (see Fig. 15.5).

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Piaget’s Schema

New Knowledge

Not Congruent with Current Schema

Congruent with Current Schema

Assimilation

Accommodation

New Schema

Current Schema

Fig. 15.4  Schematic of Piaget’s Schema

Figure 15.5 summarises Piaget’s model updated to incorporate abstention. Abstention is not an uncommon problem amongst postgraduate doctors in training. The key to addressing this is to make the trainee aware of the process by which changes in schemas occur and to recognise and acknowledge that unlearning and the potential stress associated with unlearning while continuing in practice is part of that process. We can see that there are parallels between Eraut’s routinisations, Dreyfus and Dreyfus plans and Piaget’s schemas. Each provides plans of action which allow thought to be transformed into actions. Transformed knowledge changes behaviour by being incorporated into a plan of action (schema or routinisation); when the plan is transformed into action that action is seen as a change in behaviour (learning). New knowledge can result in a reorganisation of an existing plan or the development of a new plan. Plan [Dreyfus] Schema [Piaget] Routinisation [Eraut] Knowledge

Action

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Piaget’s Schema

New Knowledge

Not Congruent with Current Schema

Congruent with Current Schema

Assimilation

Current Schema

New Schema

Abstention

Accommodation

Fig. 15.5  Schematic of Piaget’s Schema

Cognitive Basis for Skill Acquisition Memory In the early stages in the acquisition of a particular skill we must consciously think as we carry out each stage of the skill (c.f. the steps of a Schema) as the information is held in short-term memory and “rehearsed” by the verbal and visuospatial rehearsal systems in the working memory. With repeated practice the pathways through which we actively think through the stages become “hardwired” that is to say the repeated stimulation of the neurons, dendrons, spines and synapses in that pathway increases the number of connections to the extent that the pathway becomes established in a physical sense. There are two consequences of this: 1. We have to commit less and less conscious thought to putting these pathways together. 2. Other existing subconscious pathways connect into our pathway and add in additional information to facilitate the skill (e.g. proprioceptive input so that we do not have to look directly as we do psychomotor activities). This is analogous to the way we learn to balance on one leg. Initially we have to consciously adjust our position to maintain balance. With experience we can maintain our balance with little conscious thought, as we make use of subliminal and intrinsic pathways (e.g. proprioception) which connect into the initially explicit

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pathway. This allows us to balance, even with our eyes closed and with little or no conscious effort. Note that as we internalise our route by hardwiring it we need to expend less conscious effort to execute it. Our actions become more rapid and intuitive in contrast to the slower and more deliberative conscious thought processing associated with the early stages of skill acquisition. This is because at the earliest stages we have to think consciously about what action to take next and execute the action before thinking about the next action. In contrast, as the pathway becomes hardwired, action follows action with increasingly less conscious intervention. Finally, when the pathway is fully hardwired it can be followed with no conscious intervention. The hardwiring of the pathway is analogous to the hardwiring of a skill. As the skill becomes hardwired the execution of the skill becomes more fluid as the need to intersperse each individual action with a pause for thought to determine the next action is minimised. This increase in fluidity is accompanied by a reduction in the time required to execute the skill (see Fig. 15.6).

Thought 1

Thought 2

Thought 3

Thought 4

Thought 5

Conscious Explicit (slow and deliberative)

Action 1

Thought 1

Action 2

Thought 2

Action 3

Thought 3

Action 4

Thought 4

Action 5

Thought 5

Establishment of neural pathways and internalisation

Action 1

Action 2

Action 3

Action 4

Action 5

Action 1

Action 2

Action 3

Action 4

Action 5

Unconscious Tacit (rapid and intuitive)

The thickness of the arrows denotes the speed of processing between actions

Fig. 15.6  Diagrammatic representation of the process of hardwiring

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Psychomotor Skill Acquisition In the chapter on learning we discussed a taxonomy for the psychomotor domain on four levels as taught on courses such as the Advanced Paediatric Life Support and European Paediatric Life Support courses1: Stage 1: Animating clinical expertise. Demonstration of the skill, performed at real speed with or without speech. Stage 2: Reinforcing components of clinical expertise. Repeat demonstration with dialogue, providing the rationale for actions. Stage 3: Part transition of responsibility for the skill from instructor to candidate. Repeat demonstration guided by one or more of the learners. Stage 4: Independent candidate practice. Repeat demonstration by the learner and practice of the skill by all learners. Although this taxonomy is suitable for describing the stages for teaching a skill in the skill laboratory, it does not describe the transition from the skills laboratory to the clinical setting. I propose a comprehensive taxonomy below which covers the full pathway of skill acquisition from novice student to expert practitioner and maps to the skills laboratory taxonomy. Comprehensive taxonomy: • • • •

Level 1: Observe: The student observes the instructor demonstrating the skill. Level 2: Reproduce: The student demonstrates the skill to the instructor. Level 3: Practice: The student practices the skill. Level 4: Refine: The practitioner performs and refines the skill in the clinical setting. Merging the comprehensive and skills laboratory taxonomies gives:

• Level 1: Observe –– Stage 1: –– Stage 2: –– Stage 3: • Level 2: Reproduce –– Stage 4: • Level 3: Practice • Level 4: Refine At level one (stage one) the instructor demonstrates the skill to the student without verbally describing it (i.e. in a silent run through). This allows the sequence to be committed to working memory using the visuospatial scratch pad. At level one (stage two) the instructor, by simultaneously demonstrating and describing the skill verbally allows the sequence to be committed to working memory using the phonological loop (note as previously discussed that visuospatial data can be rehearsed in the phonological loop by silently verbalising it).

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Note that this splitting of the instruction process to visual only then visual and verbal allows both components of short-term memory to be accessed. As previously discussed both phonological loop and visuospatial scratch pads can work at the same time without interfering with each other. Using both systems simultaneously increases the likelihood that the student will retain the sequence while it is being held in working memory prior to the sequence undergoing hardwiring into long-­term memory. At level one (stage three) the student describes the sequence while the instructor is demonstrating the skill; this serves to confirm to the instructor that the student has committed the correct sequence to working memory and reinforces the sequence for the student. The student is not permitted to advance past this stage until they can describe the stages of the sequence being demonstrated by the instructor precisely. At level two (stage four) the student demonstrates the skill while explaining the sequence to the instructor. The instructor observes to ensure the student is following the correct sequence. It is at this stage that competence is usually assessed. This describes the four-stage approach to teaching a new skill. As noted these four stages occur in the first two levels of the proposed psychomotor domain taxonomy. There are two further levels in the proposed psychomotor domain taxonomy. In these two levels the skill learnt in the skills laboratory is translated into actual performance. At level three the student continues to practice the skill to embed the hard wiring. If the student does not practice the sequence a number of times beyond stage four, then for all but the simplest sequences they are likely to forget the precise steps as they are still relying predominantly on the visuospatial scratch pad and phonological loops to store the sequence. At level four the practitioner applies the skill in the actual clinical setting. With further experience modifications to that pathway occur based on an individual’s personal experience. That is why no two experienced individuals will execute the same basic skill or action in exactly the same way. Note that as we internalise the skill by hardwiring, we need to expend less conscious effort in executing it. Our actions become more rapid and intuitive in contrast to the slower and more deliberative conscious thought processing associated with the early stages of skill acquisition (see Fig. 15.7).

Competence We now need to review the subject of competence in the light of this revised definition of skill and the structure of skill sets. As previously discussed there is a lack of concordance in the literature on the definition of the term competence and its relationship with performance. I will propose some definitions which accord with current medical practice and provide a common language with which to work. As well as discussing competence and performance I will also include the terms capable and capability in my definitions as

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Level 1: Observe

Short Term Memory

The student observes the instructor demonstarting the skill

Conscious Explicit

(Slow and deliberative)

Stage 1: The instructor executes a silent run through of the skill with no commentary Stage 2: The instructor executes a run through of the skill with commentary Stage 3: The instructor executes a run through of the skill with commentary from the student

Short Term Memory

Thought 2

Thought 3

Thought 4

Level 2: Reproduce

Thought 5

The student demonstrates the skill to the instructor

Conscious Explicit

Stage 4: The student executes a run through of the skill while giving their commentary

(Slow and deliberative)

Action 1

Action 2

Action 3

Action 4

Action 5

Long Term Memory

Unconscious Tacit (rapid and intuitive)

Conscious / Unconscious Explicit/Tacit

Action 1

Action 2

Action 3

Level 3: Practice Action 4

Action 5

Action 3

Action 4

Action 5

Action 3a

Action 4a

The student practices the skill

Long Term Memory Action 1

Action 2

Level 4: Refine The practitioner performs and refines the skill in the clinical setting

Fig. 15.7  Diagrammatic representation of the acquisition of a psychomotor skill

these terms are used interchangeably with those of performance and competence in current practice: • Competency: A programmed sequence of steps designed to achieve, within a given context, a defined outcome. I will restrict this term to that which can be assessed in the controlled environment of the skills laboratory or classroom. A competency may involve more than one skill set. • Competence: Demonstrating the ability to execute the programmed sequence of steps, within a given context, in order, with fluidity and in a timely manner. Absolute adherence to the sequence is a mandatory requirement. Note that competence is assessed in terms of process rather than the outcome. • Competent: An individual is deemed to be competent when they have been formally assessed as having demonstrated competence in a competency. • Performance: The ability to achieve a defined outcome in a real-world situation by a number of possible routes. Performance will often be based on the applica-

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tion of competencies acquired and demonstrated in the skills laboratory or the classroom. Performance is assessed against outcome rather than process and as such it is not a requirement that the individual steps in a competency have been followed in sequence to achieve that outcome. Often, as a result of experience, there are fewer steps than demonstrated in the original competency. • Capable/Capability: These are terms which have been used to indicate competence in some circumstances (“they have shown themselves to be capable of executing the skill in the clinical skills lab”) and performance in others (“they are very capable”). I suggest that we limit the use of the term capable and capability to situations where we are referring to current or future performance in the real-­world setting. –– Capability thus denotes future potential when discussing a candidate whose attainment in the skills laboratory is sufficient to give assurance that they have the potential, i.e. they have been assessed as being competent in the competency in the skills lab and have therefore shown that “they have the capability” of performing the skill in the clinical setting in situations they have not yet encountered. –– Capable thus denotes actual performance when discussing a candidate who has demonstrated the ability to achieve the defined outcome in the real-world situation, i.e. they have been working in the actual clinical setting, by whatever route and have shown themselves to be capable of using the skill in that setting. The use of the term capability to denote future potential based on achieving competence in a competency in a skills laboratory setting is effectively a judgement that current assessment tools have limitations in terms of assessing all the elements present in actual clinical practice. We can however make a judgement that an individual has shown the ability to work at the higher levels of the domains of learning sufficient to provide reasonable assurance that they can problem solve in unique situations. The definition of a competency given above is couched in terms of a sequence of actions designed to achieve a defined outcome and suggests that the aim of the instruction process is to get the individual to a stage where they can reproduce that sequence of actions with a degree of fluidity in the correct sequence and in an acceptable time period. The actions may be predominantly psychomotor (e.g. learning how to put in a chest drain), cognitive (learning how to interpret a set of blood gas results), affective (breaking bad news in a sensitive manner) or more commonly, a combination of all three. As stated above, once an individual has demonstrated that they can reproduce the programmed sequence of actions with fluidity in the correct sequence and in a timely fashion they are deemed to have demonstrated competence in that competency and are said to be competent. Deviation from the programmed sequence of actions, a lack of fluidity or an unacceptably long time to execute the sequence would lead to a failure to demonstrate competence in that competency. This definition of competence fits with the use of a checklist and limited time per station to determine competence in an OSCE (Objective Structured, Clinical Examination) station. OSCEs only deal with explicit knowledge; they cannot be

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Table 15.1  Definitions applicable to the skills laboratory and the real world

Skills laboratory Competency Competence Competent Capability (potential)

Real world

Capable (Actual) Performance

used to assess the tacit component of a skill. This limits their usefulness when using them to predict future performance and outcomes where that outcome will often rely upon the use of tacit knowledge and skills. The assumption underlying OSCEs is that if you followed the sequence defined in the OSCE in real-life situations you would achieve the correct outcome in most circumstances. • OSCE = Competence (process-based) • Workplace-based assessment = Performance (outcome-based) A note on the term competent. In this chapter we have used the term competent to denote the achieving of competence in a competency as demonstrated in the skills laboratory and have noted that this does not guarantee that the student will be able to execute that competency in practice in the real world. In the chapter on skills we used the term competent practitioner in relation to a stage in the Dreyfus and Dreyfus model of skill acquisition. To avoid confusion in this matter we will use the term competent student to refer to the achievement of competence in a competency in the skills laboratory and the term competent practitioner (and by extension proficient practitioner and expert practitioner) for the stages of attainment in the Dreyfus and Dreyfus model. These definitions accord with our differentiating between being competent in a skill as demonstrated in the skills laboratory which shows a student’s potential (showing capability) and being a competent practitioner in the real world with all of its complexity and unintended consequences (being capable). It goes without saying that a prerequisite to achieving competent practitioner designation in the Dreyfus and Dreyfus model is the acquisition of the competencies required to work in that particular environment (see Table 15.1).

Assessment I have considered the definitions of the four levels of Miller’s framework2 in relation to the proposed definitions for competency, competence, competent, capability and capable and find that the terms in the current framework as proposed by Miller do not map well with these definitions. I, therefore, propose the modification to the mapping as in Fig. 15.8.

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Does (Action)

Does (Performance)

Shoes How (Performance)

Shoes How (Competence)

Knows How (Competence)

Knows How (Sequence)

Knows (Knowledge)

Knows (Knowledge)

Miller’s Framework

Modified Miller’s Framework

Fig. 15.8  Miller’s framework and modified Miller’s framework

In the modified framework the basic level “knows” is defined as knowledge as in Miller’s framework. This refers to the generic professional knowledge we bring to any learning task as a professional; e.g. for learning to place a chest drain we would assume that the student had the basic anatomical and physiological knowledge required to learn the skill. These may be revised as part of the competency, but it would be uncommon to start teaching the competency if an individual was deficient in this basic knowledge. The second level “knows how” is defined by Miller as competence, but I have modified it to be sequence. The student will at first commit the sequence to memory as a prelude to achieving competence. The sequence may be thought of as a Schema (Piaget), Routinisation (Eraut) or Plan (Dreyfus). Committing the sequence to memory is a necessary prerequisite to practicing the sequence to a level where competence can be demonstrated. The student will be able to demonstrate the sequence in practice, but the execution will be slow and halting as they consciously recall the individual steps to be followed. The third level “shows” is defined by Miller as performance, but I have modified it to be competence. Once the sequence is committed to memory and reproduced enough times the sequence is “hardwired” to the extent that the individual can execute it in order, with fluidity and in an acceptable time frame within the skills laboratory environment. To transition from “knows how” to “shows” may take a considerable amount of practice for some sequences. A student can only be designated as having achieved this stage when they have successfully completed a formal assessment of competence (e.g. by an OSCE examination). The final level “does” is defined by Miller as action, but I have modified it to be performance. Performance is what we do in real life, with all of its complexity, variability and unexpected consequences. Once an individual has achieved competence in a specific competency they can start to apply this in the real clinical setting. There are three consequences when we start to apply the skills derived from laboratory competencies to the real world:

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• Patients and circumstances in the real world vary considerably compared to the standardised assumptions made when designing lab-based competencies. • The learnt sequence has more stages than the experienced practitioner will eventually use in real practice, so initially it takes longer to execute. • In the performance environment individuals are assessed in terms of outcome rather than process. As the practitioner starts to work in the real world environment they start to make subtle modifications to the sequences of their competencies based on their real-­ world experience. Modifications that work are reinforced; those that do not are rejected (see the acquisition of Competence in the Dreyfus and Dreyfus model). As no two practitioners are exposed to the same series of cases, no two experienced practitioners will practice in precisely the same way. By restricting the term competence for use within an assessment framework we are not saying that competence is unimportant; only that the acquisition of competence in a defined series of competencies is the ticket that admits a competent practitioner into the arena of professional practice; competence is the starting point of professional practice, not the end point. My concern with loosely using the term competence in relation to actual professional practice is that competence does not necessarily predict performance in practice. It is not an uncommon experience to find that a trainee having passed a competency-based assessment, e.g. Advanced Trauma Life Support (ATLS)/ Advanced Paediatric Life Support (APLS)/Advanced Life Support (ALS)/ European Paediatric Life Support (EPLS) course, on returning to the workplace is unable to translate that competence into actual performance. Competence provides a blueprint that allows a practitioner to achieve a defined outcome in most circumstances, but as with blueprints in architectural practice situations in the real world may lead us to have to adapt the blueprint to the specific situation. Competence is assessed on the basis of process; performance is assessed on the basis of outcome. Competence is conscious and explicit, performance is explicit and tacit depending on the circumstances and needs of the specific situation. Repetition of the competency results in modification and internalisation, the acquisition of a tacit body of knowledge and the potential to progress to proficiency and expertise. Progressing to the relevant affective levels of engagement goes hand in hand with moving up the Dreyfus progression.

Summary In summary, skill is the ability to manipulate the environment to achieve a defined goal. Any particular situation will involve the use of several skill sets. A skill set comprises the unique combination of psychomotor, cognitive and affective elements combined with relevant tacit and explicit knowledge required to execute a specific task (e.g. cannulation).

Reference

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The stages in the acquisition of a new skill set can be described in terms of a four-level model: observe, reproduce, practice and refine. As individuals progress up the five skill levels defined by Dreyfus and Dreyfus (Novice to Expert) the skill set elements become progressively hardwired into neural pathways. This hardwiring is the neurophysiological basis for the development of an increasing body of tacit knowledge that results in the skill being executed faster and with more fluidity. A competency is a programmed sequence of steps designed to achieve a defined outcome. A competency may involve one or more skill sets. Competence is the term used to describe the ability to execute a programmed sequence of steps in order, with fluidity and in a timely manner within a skills laboratory or other learning environment. A person is said to be competent when they have demonstrated competence in a competency. Demonstrating competence requires absolute adherence to the steps in the programme: It is process driven. Performance is the term used to describe the ability to achieve a defined outcome in a real-world situation by a number of possible routes. Assessment of performance is based on demonstrating achievement of the desired outcome: It is outcome driven. The term capability is used to denote future potential in a competent person (“they have shown themselves to have the capability to execute the competency in the real working environment”). The term capable denotes actual performance in the real working environment. These definitions can be used to reformulate the stages described in Miller’s framework (Knows, Knows How, Shows Does) from knowledge, competence, performance and action to knowledge, sequence (or schema), competence and performance. In the next chapter we will extend Argyris and Schőn’s theories of action to a general model of how thought is transformed into action.

Reference 1. Bullock I, Davis M, Lockley A, Mackway-Jones K. Pocket guide for clinical instructors (3rd edn). Chichester: Wiley Blackwell (BMJ Books); 2015, pp.  29–31. From Bullock I, Davis M, Lockley A, Mackway-Jones K.  Pocket Guide for Clinical Instructors (Third Edition). Chichester: Wiley Blackwell (BMJ Books); 2016. © 2016. Reprinted by permission of John Wiley and Sons, Publishers.

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When I speak of transforming thought to action I am referring to a schematic of the process rather than describing or mapping out the specific neural pathways which physically act to transform thought to action (see hierarchy of comprehensive entities discussed earlier). In the first section I discussed several models that describe aspects of how thought is transformed into action: • • • •

Theories of Action (Argyris and Schőn) Schemas (Piaget) Plans (Dreyfus and Dreyfus) Routinisations (Eraut)

These models span a spectrum from describing the actual action itself (schemas) to describing how a series of actions are ordered to achieve a specified outcome (plan). It is my aim to extend and integrate these models. For the purposes of this chapter I will divide the process of transforming thought into action into two sections: • The origin of the driver(s) to act • Transforming the driver(s) into action

The Origin of the Driver(s) to Act I will use Argyris and Schön’s theories of action to serve as the basis for an extended model for describing the transformation of thought to action (see Fig. 16.1). Argyris and Schön note that maintaining our governing variables within acceptable limits is a major determinant of our actions. Although central to the concept of theories of action, Argyris and Schön give little detail about the nature of governing variables but do give a few examples: © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_16

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Governing Variables

Action Strategies

Consequences (Behavioural World)

Fig. 16.1  A diagrammatic model of theories of action

• • • • •

Energy expended Level of anxiety Time spent with others Vitality Self-esteem

I believe that there are at least two types of governing variables: beliefs and needs. We have discussed beliefs in detail previously. Beliefs include assumptions and values. Assumptions are deep-seated beliefs which we often acquire in childhood or early adulthood. They are rarely surfaced or subjected to critical examination. Assumptions have a significant, but often subconscious, impact on our actions. Values are beliefs that we hold with a particularly high degree of conviction. Values constrain our actions while assumptions underpin our choice of values (i.e. those who hold the assumption that men are superior to women are unlikely to hold sex equality as a value). Needs may be considered according to the Hierarchy described by Maslow [1].

Maslow’s Hierarchy of Needs Maslow described his theory of human motivation in terms of five needs. This model is often illustrated as a pyramid (though not so by Maslow) with the basic needs on the bottom. The levels are shown in Fig. 16.2. • • • •

Physiological needs: e.g. food, drink, shelter, warmth, sleep Safety needs: e.g. security, order, stability Belongingness and Love needs: family, affection, relationships Esteem needs: achievement, status, responsibility, reputation [What we do to impact on how others perceive us] • Self-actualisation needs: self-fulfilment. [What we do for our own self-fulfilment] The desire to attain our needs drives our actions.

Herzberg’s Hygiene and Motivational Factors

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Self Actualisation

Esteem

Belongingness and Love Needs

Safety Needs

Biological and Physiological Needs

Maslow’s Hierarchy of Needs Fig. 16.2  Maslow’s hierarchy of needs

Herzberg’s Hygiene and Motivational Factors In addition to our governing variables which define what we want, I would propose that there is a second class of variable which we will term contingent variables which define what we have to do. Contingent variables are determined externally and are often (though not always) outside our control. Contingent variables may enhance or inhibit the achievement of our governing variables. There are a number of classes of contingent variables, e.g. laws, rules, social norms, etc. One specific class studied by Herzberg relates to factors in the workplace that can inhibit or facilitate the maintenance of our governing variables. Herzberg described his theory of workplace motivation which characterised motivational factors (job satisfiers: facilitators) and hygiene factors (job dissatisfiers: inhibitors) and summarised his work thus (see Table 16.1): We can expand….by stating that job satisfiers deal with factors involved in doing the job, whereas job dissatisfiers deal with the factors which define the job context [2].

So although according to theories of action, our actions are primarily directed at maintaining our governing variables, external factors can influence them. It is the interaction between governing variables and contingent variables that ultimately determine our actions. Although contingent variables are often outside our control, some, e.g. workplace factors, are potentially subject to control if we recognise them as counter to our governing variables and decide to change our job or role.

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Table 16.1  Herzberg’s hygiene and motivational factors

Inhibitors Working conditions Policies and administrative practices Salary and benefits Supervision Status Job security Co-workers Personal life

Facilitators Recognition Achievement Advancement Growth Responsibility Job challenges

Modified Structure of Theory of Action So we can revise the structure of theories of action to reflect this from the model in Fig. 16.1 to the model in Fig. 16.3. For the purpose of the extended model, when I refer to needs I will always be referring specifically to Maslow’s hierarchy of needs; when I refer to facilitator and inhibitor contingent variables I will be borrowing the concept from Herzberg to describe the two types of contingent variable but recognising that work-place-­ related contingent variables are only one of several classes of contingent variables (others include laws, rules, social norms, etc.).

How the Driver to Act Is Transformed into Action? The specific driver(s) which lead us to acting are a compromise between what we want (governing variables) and what we have to do (contingent variables), noting that some contingent variables may align with our governing variables. Our drivers set our goals in life by defining what we want to achieve (realising our governing and contingent variables). As discussed in the section on the Dreyfus and Dreyfus model of skill acquisition our goal(s) define the perspective we take on the environment. That perspective in turn defines the elements of the environment which we need to manipulate in order to achieve our goal(s). Actions or skill sets are the means by which we actually manipulate these elements to achieve a specific outcome. It is the aggregate of all of the outcomes of individual actions that leads to us ultimately achieving our goal. For the purpose of the extended model I will use the term “Plan” (after Dreyfus and Dreyfus) to describe the process we use to map out the series of actions or skill sets required to manipulate the elements of the environment to achieve our goal. There are few actions we execute which do not impact on both our real world and our behavioural worlds. So we can consider the extended model derived from theories of action as a starting point for the development of an integrated approach to an understanding of the impact of our actions on the real world and our behavioural worlds. We can summarise the revised model as shown in Fig. 16.4.

Summary

Governing Variables

141

Beliefs Needs

Drivers

Contingent Variables

Action Strategies

Outcomes

Action

Outcome

Facilitators Inhibitors Thought

Fig. 16.3  Modified structure of theory of action to incorporate Maslow and Herzberg’s models

Governing Variables

Beliefs Needs

Drivers

Contingent Variables

Goal

Perspective Plan Elements

Action Outcome

Impact

Real Behavioural

Facilitators Inhibitors

Fig. 16.4  Summary of model to date

Summary In summary we transform our thoughts in actions by combining the things we want (governing variables) with the things we have to do (contingent variables) to derive drivers that define our goals. Our governing variables consist of beliefs and needs; needs are defined using Maslow’s Hierarchy. Our contingent variables consist of facilitators and inhibitors which are defined by Herzberg’s Hygiene and Motivational Factors. Our goals determine the perspective we take on the world which itself defines the elements of the environment we need to manipulate to satisfy our drivers. Identifying the relevant elements of the environment allows us to develop a plan to achieve our goal(s). A plan consists of a series of actions with expected outcomes. Each action has an impact on the real and behavioural worlds we inhabit. In the next chapter we will extend the model to include reflection and use this to develop a structured model of reflection.

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References 1. Maslow AH. A theory of human motivation. Psychol Rev. 1943;50(4):370–96. 2. Herzberg F, Mausner B, Snyderman BB. The motivation to work (2nd edn). New York: Wiley; 1959. From Herzberg, F, Mausner, B, Snyderman, BB. (1959). The Motivation to Work (2nd edn). Copyright © 1959. New York: John Wiley, Reproduced with permission of the Licensor (Taylor and Francis Group LLC (Books) US) through PLSclear.

Reflection Revisited

17

It is helpful to begin by reviewing the process by which reflection is triggered. Reflection can be triggered by an event occurring in the real world or one of our behavioural worlds. The trigger may be initiated subconsciously, when an action is not producing the expected outcome and the problem is surfaced to the conscious mind to produce a solution. Or consciously when the task at hand is high stakes and requires conscious deliberation of each step, e.g. a delicate operation on the brain. Whether the trigger is initiated consciously or subconsciously reflection may occur in action or on action depending on whether the trigger occurred in the action present or not (see Fig. 17.1). Having established how reflection is triggered we will now discuss what we reflect on.

What we reflect on As noted in the chapter on Theories of Action and Transforming Thought into Action, our actions are driven by the interaction of our desire to maintain our governing variables within an acceptable range and the requirement to comply with externally mediated contingent variables which may enhance or inhibit our ability to maintain our governing variables. The interaction of our governing variables and contingent variables leads to the development of driver variables which define our goals. Goals give us a specific perspective on a problem and determine those elements of the environment which are relevant to us achieving our goals. A perspective effectively reduces the number of variables (elements) we have to manipulate to achieve our goal to a manageable level and allows us to formulate a plan. A plan consists of a series of actions designed to achieve the outcomes we require to progress towards our goal. The goal may be seen as the aim and the outcomes of our actions the objectives required to achieve that aim; just as a series of stepping stones (the individual objectives) allow us to © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_17

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Real Behavioural

Trigger

Reflection

Conscious Subconscious

In Action On Action

Fig. 17.1  Schematic for how reflection is triggered

Governing Variables

Beliefs Needs

Drivers

Contingent Variables

Goal

Perspective Elements

Plan

Action Outcome

Impact

Real Behavioural

Trigger

Conscious Subconscious

Reflection

In Action On Action

Facilitators Inhibitors

Fig. 17.2  The transformation of governing and contingent variables into actions

cross a river to get to the far bank (the overall aim). All actions lead to outcomes which impact, to varying degrees, on our real world and one or more of our behavioural worlds (see Fig. 17.2). The impact of the outcomes of our actions on the real and/or our behavioural worlds are the potential triggers for reflection. When the outcome of our actions is inconsistent with the aim of achieving our goal either in the real world or one or more of our behavioural worlds, the inconsistency triggers a conscious or subconscious response. The reflection which arises as a result of that trigger may then be directed at one of two levels: • On the actions, the outcome of those actions and the plan which defined those actions • On the perspective taken of the situation, the elements that perspective specifies and the goal which defined that perspective. Although there is much overlap between the two, the first level primarily triggers reflection-in-action and the second reflection-on-action. This is because actions and outcomes tend to impact on the action present and create real-time problems. In general, it is only a recurrent failure to reconcile problems associated with a specific plan that triggers reflection on the plan itself, the origin of the plan, the goal and the perspective and elements defined by that goal. The diagram shows that there is also a third level at which reflection can be directed: • On your governing variables and the needs and beliefs that underlie those governing variables • On your contingent variables, the origins of your contingent variables and how they enhance or inhibit your governing variables • On your theories in use, your espoused theories, the behavioural worlds they create and the congruence between them

Reflect on Your Actions, the Outcome of Those Actions and the Plan Which Defined… Metacognitive Governing Variables

On-Action

In-Action

Beliefs Needs

Drivers

Contingent Variables

145

Goal

Perspective Elements

Plan

Action Outcome

Impact

Real Behavioural

Trigger

Conscious Subconscious

Reflection

In Action Metacognitive On Action

Facilitators Inhibitors

Fig. 17.3  Schematic of the three types of reflection

Because governing variables and contingent variables are deeply seated drivers, it is uncommon that either reflection-in-action or reflection-on-action addresses them. To uncover these, we need to use a particularly deep type of reflection which we will term metacognitive reflection (Fig. 17.3). We will examine each of these levels in turn.

 eflect on Your Actions, the Outcome of Those Actions R and the Plan Which Defined Those Actions As a prelude to this discussion, we need to understand the structure of the action– outcome cycle. Life’s plans are a series of iterative approximations to reality. No two situations are ever the same. You may go to work by the same route in the same car at the same time every day, but the infinite number of variations for each parameter you may meet means that each day is unique. We do not, however, devise a new plan for each day. We use the most appropriate of our existing plans (the getting to work yesterday plan, the getting to work when the schools are on holiday plan, etc.) and modify it to fit. As we subconsciously check our progress against the plan we confirm the plan’s appropriateness. Where there is a significant deviation from the plan (sufficient that it cannot be addressed by our subconscious which generally manages to put in place corrective actions for most variations from the plan) then that discrepancy is surfaced to our conscious attention and we reflect in action in order to arrive at a solution to the problem, i.e. at the time the problem is at hand. We examine the action–outcome cycle that led to the problem and reframe it. This iterative series of reflective steps are triggered by a subconscious recognition that a particular outcome is not what was expected for the given action. That may be because the action was the wrong action, or it may just be an unintended consequence of the action, totally unpredictable and a feature of living in a highly complex world with many potential variables (elements) which we can manipulate and which we must simplify in order to act (i.e. we have to produce a simplified view of the world in order to act). We simplify the world by taking a perspective which reduces the number of variables (elements) we need to manipulate to make a decision. One or more of the variables we have excluded due to the perspective we

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have taken can, however, emerge unexpectedly as a foreground variable which will need addressing. Note that the first stage is to review the action to determine if it was the correct action. It would only be after several iterations of the application of reframing and reflective problem-solving to the action–outcome cycle that we would consider the problem to be the plan itself. Our plans are very resistant to change so we tend to make the minimum change required to produce the correct outcome, wherever possible. It is worthwhile re-emphasising that in our daily life much of what we do is unconscious and unreflective as long as things are going according to plan. This is important as it allows us to act efficiently and effectively. If we had to decide what we wanted to do and how to do it in every situation every time we met that situation the progress of life would be slow and we would fail to live effectively. It is only when those automatic subconscious processes (plans, etc.) fail to deliver what we want to achieve that we need to reflect. Similarly, if we consciously responded to each non-compliance by changing the plan, we would constantly be applying scarce conscious thought processes to modifying our plans. There is a benefit in most circumstances in being able to choose a readily available pre-existing plan and modify it to achieve the desired goal. Existing plans have been tested and found to work, so modifying them poses less of a risk than formulating a completely new plan. In unique situations we will often use elements of existing plans and monitor their performance against the outcomes needed to achieve our goal, e.g. to get to London start by leaving Sheffield (use existing series of plans depending on time of day, weekday and whether it is school holidays or not). Once having left Sheffield head south then by a series of course corrections informed by the road signs get to London. We should note the similarity between Dreyfus and Dreyfus’s perspectives and Schön’s frames. Which all give us a perspective on the world and serve to narrow down the range of variables we need to consider when coming to a decision about which actions we should take. A plan consists of a series of actions, each designed to deliver a specific outcome which moves the plan forward towards our ultimate goal. Plans are developed consciously but as they evolve and are rehearsed they become progressively more subconscious (e.g. the driving to work in the morning plan). However, in high stakes situations, we may choose to execute the whole plan or sections of the plan consciously. When we consciously choose to actively review the outcome of our actions in real time, even if those actions seem to be going to plan, there are three consequences: • We cannot use our limited conscious thought processes for any other purpose. • We slow down the action–outcome cycle as conscious thought is slow and deliberative while tacit action is fast and intuitive. • We cannot access the vast repositories of tacit knowledge.

Reflect on Your Actions, the Outcome of Those Actions and the Plan Which Defined…

Usually Subconscious

Plan

147

Usually Conscious

Reality

Action 1

Planned Outcome 1

Congruent

Actual Outcome 1

No

Reflection in Action

Yes Action 2

Fig. 17.4  The action–outcome cycle and reflection in action

As a consequence, conscious review is usually reserved for very specific activities, e.g. performing delicate surgery such as on the eye, when the speed of surgery is less important than the outcome and where the surgeon has no other actions to take (they are provided with an anaesthetist to manage the patient, a scrub nurse to hand him instruments, etc.). The first action in a plan when executed has an outcome, this outcome is compared with the desired outcome, if they are congruent (not necessarily precisely as expected but sufficient to progress towards the goal) the plan proceeds to the next action (see Fig. 17.4). If everything goes according to plan, then the goal is finally reached as the last outcome of the final action leads to the achievement of the final goal (see Fig. 17.5). This is an iterative process with the last stage being reflection-on-action if the final goal has not been achieved or if the individual feels that a review of a successful cycle would be beneficial to inform future cycles. We can reflect in action when our subconscious alerts us that the outcomes of our action appear not to be congruent with the expected outcomes, given the assumptions we made in planning our actions. This is a subconscious process most of the time, although as noted above on occasion we may choose to surface the plan to be executed fully in the conscious domain. If the outcome is not the expected outcome, the problem is surfaced to the conscious mind to review the discrepancy. A process of reflection-in-action is initiated. If the discrepancy is found to give an outcome which is congruent with the aims of the plan, then the plan proceeds to the next action. If not then other potential actions are examined to see if they may give the desired outcome, i.e. the problem is reframed (see Fig. 17.6).

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Usually Subconscious

Plan

Usually Conscious

Reality

Action 1

Planned Outcome 1

Congruent

Actual Outcome 1

No

Reflection in Action

No

Reflection in Action

No

Reflection in Action

Yes Action 2

Planned Outcome 2

Congruent

Actual Outcome 2

Yes Action 3

Planned Outcome 3

Congruent

Actual Outcome 3

Yes Action 4

Planned Outcome 4

Congruent

Actual Outcome 4

No

Reflection in Action

Yes Action 5

Planned Outcome 5

Congruent

Actual Outcome 5

No

Actual Outcome 6

No

Reflection in Action

Yes Action 6

Planned Outcome 6

Congruent Yes

Goal Achieved

Fig. 17.5  The action–outcome cycle and reflection on action

Reflection on Action

Reflection on Your Perspective of the Situation You Are in, the Elements That… Usually Subconscious

Usually conscious

Reality

Plan

Action 1

Planned outcome 1

149

No Congruent Yes

Actual outcome 1

No

Reflection in action

New Action

Actual outcome of New Action

Congruent

Planned outcome 1

Yes Action 2

Fig. 17.6  The action–outcome cycle, reflection in action and the development of a new action

 eflection on Your Perspective of the Situation You Are in, R the Elements That Perspective Specifies and the Goal Which Defined That Perspective The world we live in is complex, with many potential variables to consider when taking any action. In order to act effectively we must reduce the number of variables we have to consider when deciding on a plan or action. We do this by taking a perspective on the problem, e.g. a clinician when confronted by the vast array of diagnostic tests (elements) available has to limit the number they request to a manageable number in order that they can interpret them. So they take a perspective (I am dealing with an acute cardiac problem) and constructing a differential diagnosis of the most likely diagnoses and testing for them (chest radiograph, electrocardiogram, cardiac enzymes, troponin C). It is not always possible to reach the right diagnosis first time, but experience tends to allow a clinician to narrow the range of possibilities to a reasonably short list. The goal of the clinician in this case is to make the diagnosis in order to treat the patient and return them back to normal health. Although reflecting on our goals, the perspective they define and the elements which are important to that perspective may occur in action, in reality during the actual execution of a plan we are so intent on moving the plan forward that we tend to stick to reflection-in-action on the action–outcome cycle and coming up with workable solutions to the problem in front of us, even if these are only quick fixes to move the problem forward. It is uncommon for us to take the time to reflect on whether we are in the right job when we are on the way to work in the morning and hit an unexpected traffic jam. We are more likely to be focusing on getting to work to get to the ward round or clinic in time. At a later quiet moment, we may take time to reflect on action and ask ourselves, “Is the daily grind of getting to work in the rush hour worth it”? We may then look to reviewing our job plan, the site we work at, etc.

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 eflect on Your Governing Variables and the Needs and Beliefs R That Underlie Those Governing Variables The term metacognitive reflection has been used in a number of ways. Here I will use the term to describe reflection about our fundamental governing and contingent variables and the resulting drivers for our actions and their validity. There are two components to our governing variables which we can reflect on: • Reflect on your beliefs, the validity of those beliefs, and the model of reality they create. • Reflect on your needs and the validity of your needs. We will consider each in turn. (a) Reflection on your beliefs, the validity of those beliefs and the model of reality they create. As we discussed in Chap. 1, much of what we consider to be knowledge is in fact only beliefs. Our beliefs are important because they provide us with our map of reality which we use to navigate the world we live in. If our map of reality is wrong, then there will be a mismatch between our expectations and reality. We can draw an analogy with a satellite navigation system. The digital map contained within the SAT NAV is made up of millions of pieces of information all individually collected and entered. We “believe” what the SAT NAV tells us is true (i.e. it connects with reality, in this case, it is an accurate representation of the true road network), but the wise driver makes constant checks as the reliability of the SAT NAV information against other sources of information such as road maps, road signs, etc.

False beliefs

Recently I was touring Scotland with my wife and was driving along the main road from John O’Groats to Thurso. The SAT NAV indicated that we were driving over the North Sea, which was clearly wrong.

By comparing the output of the digital map on the SAT NAV display with reality, by looking out of the car window, we were reassured that we were not in fact driving over the North Sea.

Reflect on Your Governing Variables and the Needs and Beliefs…

151

We continued to navigate using road signs and a paper atlas and arrived safely at our destination.

We have identified two important classes of beliefs which drive our actions, values and assumptions. Values are beliefs we hold with a high degree of conviction. Assumptions are deep-seated, often poorly articulated beliefs that underpin our value system. It is particularly important that we are aware of our assumptions as many of the biases which lead to medical errors are founded in our assumptions. Assumptions are also at the root of many breakdown in communications. Establishing guidelines and protocols and professional or organisational values are two methods for offsetting the potentially negative impact of subconscious assumptions. Organisational or professional values define acceptable behaviours, so to a degree mitigate for failure of professionals to participate in metacognitive reflection by mandating the behaviours that must be manifested irrespective of an individual’s beliefs, values or assumptions. Reflection is one means of checking that our beliefs and belief systems are congruent with reality (see Fig. 17.7). We need to regularly surface our beliefs and critically question whether they are true and if we believe them to be true, the basis for that belief. This process may be triggered by a specific event but may also be triggered by a personal commitment to examine our beliefs, independent of any trigger. (b) Reflect on your needs and their validity. Maslow’s hierarchy defines five levels of need. The highest two, self-esteem and self-actualisation, are often the precipitants of internal conflict. Self-esteem drives actions we undertake to gain recognition from our families, peer group and community. Self-actualisation drives actions which give us internal satisfaction, irrespective of how others will consider the outcome. When reflecting on needs it is generally held that Maslow’s hierarchy requires achieving success at one level before we start attending to higher levels. Practical experience suggests that this is not the case and that deficiencies in one level (e.g. a poor family environment) can be compensated for, at least in part, by success at higher levels, e.g. success at work.

Belief

Properly Justified True Belief

Reflection Rationalism Empiricism

Fig. 17.7  Reflection to confirm that a belief constitutes knowledge

Knowledge

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 eflection on Your Contingent Variables, the Origins of Your R Contingent Variables and How They Enhance or Inhibit Your Governing Variables We have discussed above how contingent variables may enhance or inhibit us achieving our governing variables. In reflecting on this it is important first to determine if the variable you are considering is a contingent or a governing variable. This can be tested in part by considering if you have the ability to personally change the importance attributed to that variable yourself with no outside input required. Often we find that what appear to be governing variables are actually contingent variables, being values or assumptions we acquire by being part of a particular professional, social, cultural or religious group. While governing variables are within our own gift to change, contingent variables require that we change our relationship with the group in order to change the priority we assign to the variable. So in the case of work we considered Herzberg’s hygiene factors. If there is a fundamental discrepancy between a specific contingent variable relating to work, then we may only have a choice of changing our job or our role in that job to reconcile the discrepancy with our governing variables.

 eflect on Your Theories in Use, Your Espoused Theories, R the Behavioural Worlds They Create and the Congruence Between Them We have discussed earlier how the model proposed by Argyris and Schőn for theories of action can be widened to include outcomes in the real world. As practitioners it is essential that there is congruence between our theories in use and our espoused theories, this is demanded by patients and also regulatory bodies (see Fig. 17.8).

Theory in Use

Reflection

Concordance

Espoused Theory

Fig. 17.8  Reflection to confirm concordance between our theories in use and our espoused theories

Summary

Governing variables

153

Action

Consequences (Behavioural World)

Reflection MSF

Fig. 17.9  The use of multi-source feedback (MSF) and reflection to test concordance between our theories in use and our espoused theories by looking at the consequences of our action on the behavioural worlds we inhabit

As discussed above our theories in use and the actions that arise from them produce the behavioural world we inhabit. Congruence between our espoused theories and our theories in action avoids the risk of dilemma’s forcing us to change our governing variables or theory in use. We can achieve this congruence by adopting model II behaviour. The best way to uncover our theories in use is to ask others whether the outcome of our theories in use meet professional norms and by reviewing the replies in terms of our own assessment. The best current system for doing this is 360° or multi-source feedback (MSF) from colleagues and patients including a self-rating using a validated questionnaire. This gives us valid information about our impact on the behavioural world we create and share with various groups (different worlds for home, work, social circles, etc.). But note that the questionnaire and the audience must be relevant to the behavioural world we are examining; individuals with a clinical and managerial role may need to use at least two questionnaires on two different audiences (see Fig. 17.9). Poor correlation between our self-assessment and that of our colleagues and patients would suggest a divergence between our espoused theory and our theory in use. Recognition that this divergence reflects a real separation between the two is the first step towards adoption of Model II behaviour and the start of a process of reflection on our governing and contingent variables. One potential outcome may be that we recognise that we are not in the correct job or role.

Summary In summary, our governing variables and contingent variables determine our actions. Our actions impact on the real and behavioural worlds we inhabit. Reflection is a process of actively examining the outcomes of our actions to inform future actions. Reflection is triggered when the outcome of our actions are inconsistent with our achieving our goal. Reflection can be in-action, on-­ action or metacognitive. Reflection in-action is generally directed at looking at our actions, the outcome of those actions and the plan which defined those actions. Reflection on-action is generally directed at looking at the perspective taken of the situation we are in, the elements that perspective specifies and the goal which defines that perspective. Metacognitive reflection is generally

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17  Reflection Revisited Metacognitive

Governing Variables

On-Action

Beliefs Needs

Drivers

Contingent Variables

In-Action

Goal

Perspective Elements

Plan

Action Outcome

Impact

Real Behavioural

Trigger

Conscious Subconscious

Reflection

In Action Metacognitive On Action

Facilitators Inhibitors

Double loop Model II

Single loop Model I

Fig. 17.10  The relationship between governing variables, contingent variables and reflection

directed at looking at our governing variables and the needs and beliefs that underlie them, our contingent variables, their origins and how they enhance or inhibit our governing variables and our theories in use and our espoused theories and the behavioural worlds they create and the congruence between them. Note that only metacognitive reflection delivers a double loop (Model II) behaviour. Multi-source feedback is one method of gathering valid information to inform that metacognitive reflection. But the mere collection of multi-source feedback without metacognitive reflection will not deliver Model II behaviour. Most reflection in action and reflection on action delivers a single loop (Model I) behaviour, but this may be a trigger for metacognitive reflection (see Fig. 17.10). In the next chapter I will describe a conceptual framework model for how doctors acquire, develop and refine their skills based on the work described in this book.

Further Reading Schőn D.  The reflective practitioner: how professionals think in action. New  York: Basic Books; 1983.

Part III Conceptual Framework

Conceptual Framework

18

None of us come to medical school or into the clinical environment without some prior knowledge or experience of medicine. It may be as a patient, as the relative or carer of a patient or as a result of exposure to medicine in the media. These prior experiences will influence our view of our learning and the training we receive. The conceptual framework I am proposing is based on the various models covered in the literature review in Part 1 and the synthesis in Part 2. It provides a language for describing and understanding how a doctor progresses from the earliest stage of skill acquisition; novice student, to the final stage of acquisition; expert practitioner. The framework has not been derived from first principles. It has been derived by a review of the literature on professional practice, my direct observation of doctors in practice and the fact that many aspects of medical practice are similar to the practice of other professionals. The core of the framework is the Dreyfus and Dreyfus model of skill acquisition. I will take it as read that this is a good reflection of how doctors acquire, develop and refine skill sets based on my nearly 40 years of working with doctors and on the work done by Benner on the applicability of the model to the nursing profession. It would be relatively straight forward to check my hypothesis by direct observation using Benner’s methodology, so this aspect of the framework is testable [1]. We will not be discussing the specific levels of cognitive attainment characteristic of each level of skill acquisition as this mapping work has not, to my knowledge, been formally carried out for medicine: I hope this book will facilitate that mapping. We do however recognise that the student will be predominantly concerned in their early career with the remembering of factual knowledge and the expert practitioner with the creation of metacognitive knowledge. For the purpose of this framework, when I am discussing the novice student I will be considering a student on a traditional curriculum where preclinical and clinical years are separated, who has finished their 2-year preclinical training and is in their undergraduate clinical training period. The transition from the novice student © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6_18

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stage to the advanced beginner student stage runs through the latter part of the undergraduate clinical years to the foundation years. Note that an experienced practitioner will revert to the novice student stage when they are entering a new field or discipline within medicine (e.g. a trainee rotating from paediatric surgery to neonatal medicine). In the sections that follow I will be using the term student to refer to novice and advanced beginners to indicate that they are not involved in delivering direct clinical care in the sense that they are not making any active decisions on that care. I will be using the term practitioner to refer to competent, proficient and expert individuals to indicate that they are directly involved in patient care but also to indicate that involvement in patient care is a critical component of their achieving and maintaining their status as competent, proficient and expert practitioners. These levels of attainment cannot be achieved only by sitting in the classroom or lecture theatre, nor can they be achieved by reading textbooks or journals. Real-world concrete experience is a prerequisite for attaining these levels of skill. Although the Dreyfus and Dreyfus model has five stages ranging from novice to expert, I will propose an additional stage: the primer stage. Priming relates to the acquisition of the knowledge implicit in the first stage of the proposed modification to Miller’s framework. For many professions, like medicine, the period of priming may be several years to reflect the volume of knowledge the student is required to absorb before entering the clinical arena. Priming describes the preclinical years of a traditional medical school curriculum and is characterised by objectivism as the acquisition of propositional knowledge is the predominant activity.

Novice Student The sentinel act which initiates the acquisition of a new skill occurs within the affective domain. Indeed, for each level of attainment in the model, achieving the appropriate level of affective engagement is a prerequisite for attaining that level. If the appropriate level of engagement is not achieved there will be no progress in that developmental stage of skill acquisition. A novice student new to a task environment becomes or is made aware by a teacher (awareness is the first stage in the first level of Krathwohl’s taxonomy of the affective domain “Receiving”) of the existence of the particular skill or task area. This awareness can initially be at a relatively low level but without awareness there will be no learning. Although this is the first stage in Krathwohl’s taxonomy, it does not mean that the student is starting with no prior knowledge. All students will bring prior experience (formal or informal) to each situation, which will give them a perspective which may facilitate or hinder their learning and may also impact on their degree of affective engagement. Because the novice student has no (or minimal) prior experience of that skill, or of working in that environment, they have nothing to guide them as to what is relevant and what is not. In order to help them acquire such experience a teacher starts

Novice Student

159

by breaking the task environment into objective context free elements called features (e.g. blood pressure, pulse, temperature, respiratory rate). The teacher gives the novice student rules which will combine these features to determine appropriate actions. Within the clinical environment the novice student will be given the objective context free elements pulse rate and systolic blood pressure as the relevant features, they are then given the rule, “if the systolic blood pressure is less than 100 mmHg and the pulse rate is more than 100 beats per minute, the patient is in a state of shock: call for help, administer high flow oxygen and one litre of crystalloid”. The sequence is: Features + Rule → Action Features and rules provide all the information the novice student requires to determine the correct action to take. The predominant instructional method for novice students is teaching, since the novice student has no context for knowing what information is important and how to use that information to make a decision. The novice student is taught the relevant features and rules by the teacher (or a teaching aid such as a text book or the internet). Because of the objective nature of the material being taught, this teaching follows the objectivist tradition. There is no requirement for the individual to interpret the features or rules or to place them into any particular context: in fact, interpretation is frowned upon. The teacher acts as the More Knowledgeable Other (MKO) and provides the scaffold to help the novice student bridge the Zone of Proximal Development (ZPD) from no knowledge of the skill or environment to feature recognition and rule-based decision-making. As the novice student has no perspective to bring to the task environment in the early stages due to lack of prior experience, their decision-making is analytical and detached, i.e. they identify features and apply the rules relevant to those features to determine the relevant action(s) to take. At this stage the novice student has no emotional attachment to the task in hand; they are merely following the taught instructions of the teacher. This lack of emotional attachment is characteristic of the lower stages of Krathwohl’s taxonomy of the affective domain. If their actions result in a poor outcome, the novice student will attribute this outcome to the teacher’s poor selection of features and rules rather than to any deficiency in them. The novice student directs their attention to following the rules and evaluates their performance by how well they remember and apply the rules rather than to the outcome of their actions. Novice students require monitoring and feedback by their teacher to ensure they follow the rules precisely. As the novice student gains experience of working in the task environment they become progressively more engaged with their tasks and within the affective domain will progress up the stages of the receiving level from awareness to:

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• Willingness to receive • Controlled or selected attention Rule following without question is the key outcome at this level. Failure to explicitly follow the given rules could result in harm to patients. This is why the definition of appropriate elements and the construction of appropriate rules combined with close supervision are essential at this stage of development. The elements of the novice stage are detailed in Table 18.1. The novice student will have gained experience of working in the particular task environment and will have demonstrated the ability to recognise features and apply rules consistently within the actual environment in which they are relevant. They will also have demonstrated increased engagement with the task within the affective domain. If an individual fails to progress within the affective domain, they are unlikely to successfully progress from novice student to advanced beginner student. The assessment of the novice student prior to progression should include an assessment of the ability to follow rules, an understanding of why the rules must be followed and an assessment of the degree of affective development in relation to the particular skill environment. There are currently no tools available to make an objective assessment of the stage of development in the affective domain so this assessment becomes a matter of judgement for the teacher.

Table 18.1  The elements of the novice stage Novice student PSYCHOMOTOR

EXPLICIT

COGNITIVE

Instructional method MKO Elements Perspective Decision-making Commitment Affective domain

Tradition Reflection

AFFECTIVE

Teaching (Objectivist) Teacher Context free None Analytic Detached Receiving (attending): progressing to: • Willingness to receive • Controlled or selected attention Objectivist/explicit Minimal: feedback on compliance with rule following

Advanced Beginner Student

161

At this point the earliest stage of reflection is introduced. This will, at a minimum, consist of the teacher discussing the novice student’s understanding of the features and rules and their adherence to them. Episodes of non-adherence are explored and the absolute requirement to adhere to the rules reinforced. Although I have stated that the novice student has no emotional attachment to the task in hand, we will all be aware of episodes when things go wrong where novices are involved that they become extremely upset and feel a major responsibility. This emotional response is inappropriate (albeit understandable) as they are simply following rules. It is the role of the teacher to reassure them that if they followed the rules they should feel no guilt. Not all students will demonstrate the same level of affective progression. Those working in a specialty in which they hope to specialise later in their career can be expected to show more progress within the affective domain. Students who do not plan to work in that specialty may show less development. Similarly, the student who progresses well within the affective domain in one area may be expected to progress less well in areas they find less appealing. It is important to ensure during a placement that the student is showing the minimal degree of affective progress consistent with meeting the minimum criteria for achieving a satisfactory assessment for that specialty and for their stage of development. Failure to progress up the affective hierarchy is likely to predict failure to achieve a satisfactory level of attainment at the next level. In addition to the appropriate level of affective engagement, learning the relevant context-free features and rules and gaining experience of working within the clinical environment is an important prerequisite to moving onto the next stage as situational awareness is required to progress.

Advanced Beginner Student The characteristic affective level required to progress as an advanced beginner student is that of “Responding”. At this level the student should be more than simply attending to the situation. The advanced beginner student should be sufficiently motivated that they are actively attending, not just willing to attend. This shows that the student has some personal committing to the learning process albeit at a low level. At this stage the instructor (note the change in terminology) will start to point out to the advanced beginner student or the student will start to recognise, if they have a sufficient level of engagement, certain elements of the environment called aspects. Aspects cannot be objectively defined the way features can, but can only be recognised within the context of the task environment. If the advanced beginner student has not progressed to the affective level of responding, it is unlikely that they will recognise aspects on their own account and will only, at best, passively acquire them from the instructor. Such passive acquisition will not serve to put the aspects in context for the student.

162

18  Conceptual Framework

An aspect gets its meaning from the advanced beginner student’s experience-­ based sense of the whole situation. Since aspects can only be specified on the basis of an understanding of the particular whole situation. Situational understanding is a prerequisite to aspect specification. The easiest means of demonstrating aspects is to point them out rather than trying to describe them. Asking a student to listen to the chest of a child with bronchiolitis then telling them that this is the characteristic chest sounds of bronchiolitis is a more effective means of conveying that recognition than trying to explain what the characteristic breath sounds of bronchiolitis sounds like. Polanyi uses the term “ostensive” to describe this method of conveying the meaning and recognition of such elements of the environment as aspects [2]. An ostensive definition conveys the meaning of a term by pointing out examples. This type of definition is often used where the element is difficult to define verbally, e.g. contrast the difficulty of explicitly describing the aroma of coffee compared with the simple ostensive process of allowing an individual to smell coffee and telling them that is the aroma of coffee. In clinical practice aspects include the quality of a pulse, the breath sounds characteristic of heart failure and the anxious/agitated state of the shocked patient. No amount of words in a textbook can substitute for having drawn to one’s attention a typical case. For some aspects it is possible to use visual or audiovisual presentations (e.g. heart sounds) and indeed these will increase the speed at which students acquire knowledge of aspects rather than waiting for random cases to present in the clinical environment. In this instance the audiovisual presentation will act as the MKO, in other instances of ostensive teaching in the clinical environment, the instructor will fulfil this role. Aspects and features are combined to produce guidelines that determine appropriate actions. Guidelines treat all features and aspects as equally important and are constructed to include as many as possible. The advanced beginner student is taught (or reads in a guideline book) that if the patient has a wheeze (situational: aspect), a respiratory rate greater than 20 breaths per minute (context free: feature) and an oxygen saturation less than 95% (context free: feature) that they should prescribe 10 puffs of Salbutamol via a spacer device and give 1–2 mg/Kg of Prednisolone. The sequence is: Features + Aspects → Rules + Guidelines → Action By definition the elements of the environment called aspects are context dependant, i.e. they are situational. Although situational, using modern teaching technology (simulation, audiovisual aids) some of these aspects can be acquired independent of the clinical environment (e.g. breath sound recognition, etc.). The predominant instructional method for the advanced beginner student is learning facilitated by the instructor (facilitated learning). Facilitated learning rather than teaching because the instructor (note again the change in terminology) cannot

Advanced Beginner Student

163

learn for the advanced beginner student, but can facilitate their learning by pointing out what is important. The instructor cannot recognise the tacit elements of the aspect on behalf of the student, hence the need for a higher level of effective engagement by the advanced beginner student. Because the advanced beginner now has to take into account, albeit at a crude level, the context in which they are working, a constructivist rather than an objectivist environment is more effective at facilitating their learning. Note however that there is still a significant objectivist element as the advanced beginner student acquires further explicit knowledge from clinical textbooks. A constructivist environment (and the epitome of constructivist environments are the ward, out-patient clinic or emergency department setting) will facilitate learning more effectively than the classroom. Group teaching at this stage will facilitate the exposure of students to a number of perspectives on any particular problem and a sharing of experience of cases seen, so widening the experience of all students. Although the advanced beginner student is now beginning to recognise the context of the task environment, like the novice student their decision-making is analytical, as they are still working to rules and guidelines provided by their instructor to determine the relevant actions required. The advanced beginner student, like the novice student, focuses on the quality of rule-following as their main outcome measure. Therefore, the advanced beginner student’s performance, while better than that of the novice student, remains slow and uncoordinated, as more sophisticated rules operating on a greater number of elements are employed. At this stage, like the novice student, the advanced beginner student has minimal emotional attachment to the task in hand. They are merely following the instructions of the instructor, even though the instructor is deferring some of the responsibility for learning to the student by the facilitated learning approach. The instructor will refer the student to textbooks or other teaching aids for the answer to questions rather than provide the answer for the student. This may even extend to minimising formal instruction and replacing it with self-directed learning or supervised tutorials. If the advanced beginner student’s actions result in a poor outcome, they will attribute this outcome to the instructor’s poor selection of features, aspects, rules and guidelines rather than to any deficiency in themselves. As the advanced beginner student gains further experience of working in the task environment they become progressively more engaged and within the affective domain will progress up the stages of the responding level from acquiescence in responding to: • Willingness to respond • Satisfaction in response

164

18  Conceptual Framework

Once the advanced beginner student has developed the necessary affective engagement and has demonstrated that they are progressing both in terms of their acquisition of new features, aspects, rules and guidelines and the ability to apply them correctly and consistently it is time to move to the next stage. Satisfaction in response is the earliest level at which there is any emotional response to the learning process by the advanced beginner student. This emotional engagement is critical to success at the next level; indeed, without it the student will remain at the advanced beginner stage in that particular skill or task. The advanced beginner student needs considerable support in the clinical setting and should not be making definitive decisions about actual patient care unless supervised by a doctor of at least a competent practitioner level. The elements of the advanced beginner stage are detailed in Table 18.2. Note that at the novice student stage and in the early phases in the training of the advanced beginner student stage, there is no tacit element to the skill set. The novice student works on rules and the advanced beginner student works on rules and guidelines. Each individual component of the novice student’s rule is explicit and most of the advanced beginner student’s guideline is explicit, but note there is the start of a

Table 18.2  The elements of the advanced beginner stage Advanced beginner student PSYCHOMOTOR

EXPLICIT

o

TACIT

COGNITIVE

Instructional method MKO Elements Perspective Decision-making Commitment Affective domain

Tradition Reflection

AFFECTIVE

Facilitated learning Instructor Context free and situational None Analytic Detached Responding: progressing to: • Willingness to respond • Satisfaction in response Objectivist/Constructivist/Explicit/Tacit Early development of reflection on action facilitated by the instructor

Competent Practitioner

165

tacit understanding of some components of aspects (try to accurately describe the characteristic range of sounds of the murmur of mitral stenosis) at the advanced beginner stage. So the first recognisable stage of the development of tacit knowledge in the skill set is at the advanced beginner student stage. We could try to deliver training by attempting to define aspects explicitly but it is more effective to start defining them tacitly, by the use of ostensive transmission of knowledge. This is not only more effective use of instruction time but also ensures that the advanced beginner student is demonstrating the appropriate level of affective engagement.

Competent Practitioner As the advanced beginner student gains further experience they acquire an increasing number of features, aspects, rules and guidelines and will experience a sense of crowdedness which will inhibit their ability to determine the correct action to take. To progress, rather than just give up in despair of ever achieving the seemingly fluent performance of their immediate superiors, they need to advance to the next stage in the affective domain, “Valuing”. This level of engagement reflects the practitioner’s active engagement in the process of acquiring his skill. This stage can only be acquired over a period of time in the task environment as it involves the practitioner starting to internalise their acceptance of the skill as a valued part of their life. The student at this stage of experience will show a consistent and active engagement with the learning process and will articulate their beliefs and exhibit attitudes consistent with those beliefs. Peers and supervisors will recognise the values held by the student and more importantly will recognise the absence or weakness in this domain if it is not fully attained. At this stage of affective development there should be emotional involvement in the decision-making process. This emotional involvement is absolutely key to success at this level. Without that emotional involvement the competent practitioner will continue to look for rules and guidelines to guide their actions and to abrogate responsibility for the outcome of their actions to the rule or guideline maker. Accepting responsibility for the outcome of their actions is the key to becoming a competent practitioner. This is a critical stage in professional development where many trainees falter. To manage the information, overload the competent practitioner has to impose some order on the task environment to narrow down the range of information required to make a decision. They do this by setting a goal and developing a plan to achieve that goal. A goal establishes a perspective that defines the situation. The competent practitioner sees the situation as a set of elements (features and aspects) of varying salience (relative importance in relation to each other). These elements are combined using rules and guidelines to determine the action to be taken. The setting of goals and choosing of plans allows the competent practitioner to reduce the crowded task environment to a manageable number of relevant elements which results in a significant improvement in his performance.

166

18  Conceptual Framework

As the competent practitioner has no objective means for determining what goal to set or plan to choose they must make a judgement about which to choose based on limited information. It is this requirement for the competent practitioner to choose a goal and plan and from that determine a course of action that introduces the emotional attachment into the decision-making process. If things go well they feel good, if things go poorly they feel responsible. The resulting positive and negative emotional experiences will strengthen successful responses and inhibit unsuccessful ones. It is this emotional involvement along with the positive and negative reinforcement associated with the outcome which sets the stage for the next stage of development. The competent practitioner Emergency Department doctor faced with three patients to review will decide which order to see them in based on clinical urgency using an algorithm based on the ABCs and a review of their physiological parameters, rather than how long they have waited to be seen. The sequence is: Goal → Perspective → Elements → Plan → Actions → Outcome At this stage the principal instructional method is facilitated reflection. The mentor (notice the change in terminology) cannot make all of the decisions for the individual or else the individual will fail to make the emotional connection between the decision made and outcome. It is this emotional involvement with the outcome which leads to increasing skill. The function of the mentor is to help the practitioner by facilitating their reflection on the outcome of their actions, intended and unintended and help them develop a system for actively analysing the outcome. The first stage is to move the competent practitioner from a subconscious reflection (a mulling over of problems in an unstructured manner) to an active process of reflection both in action on their own account and on action with their mentor. This can be achieved by providing a formal model for reflection (the Gibbs model is ideal at this stage). The mentor can reduce the number of cases required to achieve a particular level of skill by using each case as a learning opportunity. It is at this stage also that the competent practitioner first begins to acquire a true body of tacit knowledge as opposed to the acquisition of the tacit elements of aspects characteristic of the advanced beginner student. This is also the stage at which the development of established skill sets with a significant tacit knowledge component becomes evident in the competent performer with the correct level of affective engagement. An important warning sign to the mentor at this stage is the individual who is working at competent performer level but still rigidly adheres to the rules and guidelines in situations where the patient does not conveniently slot into the criteria for applying the rules and guidelines. That is not to say that the competent performer should not follow rules and guidelines, only that at this stage they will be meeting cases where the judicious use of judgement plays an important role in their development and in a successful outcome for the patient. This active process of facilitated reflection is essential for the modern graduate whose training takes place over perhaps half the number of hours per week

Competent Practitioner

167

for perhaps two-thirds of the number of years of their more senior consultant supervisors. So it is critical that maximum experience is gained from each case. By understanding the structure of skills and the reflective framework the mentor can actively support the reflective process and the competent performer can actively apply it to their reflection. The early recognition of the elements of competent performance can be expected to start developing as part of general professional training within a particular field of medicine by the CT3–ST3 level. As the competent practitioner gains further experience of working in the task environment they become progressively more engaged and within the affective domain they will progress up the stages of the valuing level from acquiescence in responding to: • Acceptance of a value • Preference for a value • Commitment Many practitioners will stop progressing at this stage and will come to be competent practitioners who can work semi-autonomously but with overall supervision. The danger of stopping progress at this level relates more to failure to keep up to date than to failure to develop one’s skills. Practitioners at this level can manage the majority of cases without supervision, requiring advice and guidance for only a small proportion of their caseload. At this stage practitioners who choose to advance their career will tend to specialise in an area; this specialisation is characterised by the practitioner exhibiting the higher levels of affective engagement. A formal system of appraisal and mentorship is a defence against the practitioner who has chosen to remain at the competent practitioner level stagnating professionally. The recognition of characteristic patterns of elements and saliencies begins at the stage of competence. As experience is gained the competent practitioner will start to recognise recurrent patterns of elements and saliencies; these are termed paradigms (diagnoses are one class of paradigm). At first the performer has few paradigms so a considerable number of real-world conditions will be subsumed under one single paradigm. With experience these paradigms are divided into subgroups with subtle differences in the pattern of elements and saliencies until they begin to resemble actual specific conditions. The process of recognition and refinement of paradigms can be left to evolve over an extended period of time while the practitioner acquires the skill of recognising ever subtler distinctions, or the process can be accelerated by facilitated reflection with a mentor, or peer group. Only experience can lead to paradigm recognition, but the active process of reviewing cases and outcomes can enhance the learning from real-life cases. The paradigm shock has the (context-free) elements blood pressure and pulse and the (situational) elements mental state and skin condition. With experience the

168

18  Conceptual Framework

performer refines this crude shock paradigm into cardiogenic, neurogenic, septic, anaphylactic, haemorrhagic and hypovolaemic shock exit paradigms, each with its additional characteristic context-free (features) and situational (aspects) elements and saliences. The competent practitioner doctor judges that the patient’s current situation is one of shock. He tests that hypothesis against the characteristic elements and their saliences in the shock paradigm and finds them to be a close but not a perfect fit. Around the shock paradigm are the six exit paradigms: cardiogenic, neurogenic, septic, anaphylactic, haemorrhagic and hypovolaemic shock, each with their own characteristic set of elements and individual saliences, a conscious review of these suggests which of them is the closest fit. Once the competent practitioner has determined the most likely paradigm (diagnosis) they consciously decide what treatment is most appropriate (see Fig. 18.1). In the modern clinical environment where trainees are training for fewer years with fewer hours of clinical exposure than their predecessors the mantra should be “a lesson from every case”. With increasing clinical cover by consultant medical staff this should become more common, even if the aspiration of a lesson per case may not actually be achievable. But note that to achieve competent practitioner status the individual MUST make their own independent decisions, take

Competent performer

Anaphylactic shock paradigm

Septic shock paradigm

Neurogenic shock paradigm

Cardiogenic shock paradigm

Shock paradigm

Conscious Decision Haemorrhagic shock paradigm

Hypovolaemic shock paradigm

Conscious Decision Administer blood

Fig. 18.1  Decision-making process for the competent practitioner

Competent Practitioner

169

responsibility for those decisions and the outcome arising from them and most importantly they must be able to follow their patient through to that outcome. The elements of the competence stage are detailed in Table 18.3. The transition to the two highest levels of skill involves the development of qualitatively different thought processes that bears no obvious relationship to the slow, detached reasoning of the novice student or advanced beginner student. Proficiency: The proficient practitioner will be experiencing the current situation from within a specific paradigm. They do not have to work out what paradigm they are in; it just presents itself to them because the present situation is similar to previous situations which they have encountered and committed to memory. This process is akin to the example of facial recognition discussed earlier. There is nothing mystical in paradigm recognition; it is derived from a prolonged period of experience within the particular professional environment the practitioner works in. While recognising what paradigm they are in without thought, the proficient practitioner must then consciously examine the elements of that paradigm and their saliencies and combine them to determine an appropriate action. The proficient practitioner makes use of maxims to guide their thinking on the action to take. Although unintelligible to the competent practitioner, maxims, derived from considerable concrete experience of actual cases and their outcomes, provide direction as to what must be taken into consideration. Table 18.3  The elements of the competence stage Competent practitioner PSYCHOMOTOR EXPLICIT TACIT

COGNITIVE

Instructional method MKO Elements Perspective Decision-making Commitment Affective domain

Tradition Reflection

AFFECTIVE

Facilitated reflection Mentor Context-free and situational Chosen Analytic Detached understanding and deciding. Involved in outcome. Valuing: progressing to: • Acceptance of a value • Preference for a value • Commitment Constructivist/Tacit Facilitated reflection on action and self-directed reflection in action

170

18  Conceptual Framework

The proficient practitioner makes use of both explicit (e.g. maxims) and tacit information to come to a decision about the correct action to take. It is at this stage that the concept of judgement comes into play as a formal experientially based part of the decision-making process. Maxim:

“Treat the fracture you see and the fracture you do not see”.

Context 1:

Wrist injury. A normal radiograph of the wrist does not preclude a scaphoid fracture; therefore, in the presence of a normal radiograph and the clinical signs of a scaphoid fracture, place in a scaphoid Plaster of Paris (POP) and review in 10 days.

Context 2:

Elbow injury. A radiograph of the elbow with no obvious bone injury but with a positive fat pat pad sign may indicate an underlying fracture. Place the limb in a collar and cuff, advise restriction of extension and review in 10 days.

Context 3:

Lower limb injury in a toddler. A radiograph of the tibia and fibula with no obvious bone injury but with clinical signs of a fracture (positive rotational stress test) may indicate a toddler’s fracture. Place in POP for 10  days and review. The competent practitioner applies judgement to determining the situation they are in, but there is very little experiential base to the particular judgement made in the early stages of their development: for them it is more an educated guess.

Competent Practitioner

171

Proficiency characterises a practitioner who has been in formal clinical practice for a number of years and has gained a significant amount of clinical experience. This level probably cannot be attained by a trainee as they rotate through posts too quickly to gain a depth of experience on the outcome of their cases where they have made the diagnostic and therapeutic decisions. Proficiency will not start to develop until the practitioner has been working in the higher specialist training phase of their training and will generally not be achieved until their early years at the consultant level. The proficient practitioner entering the resuscitation rooms will “see” that the patient is in haemorrhagic shock and will order blood while carrying out a systematic examination to determine the underlying cause of the haemorrhage so that they can determine the definitive management (see Fig. 18.2). The proficient practitioner can also gain experience by working with several more senior consultant colleagues or coaches in what would be in effect a series of masterclasses. The predominant instructional method for the proficient practitioner is coaching and personal reflection. If the competent practitioner does not transition from facilitated reflection to actively managing their own reflection they are destined to remain at best a competent practitioner. It is only the ability to actively engage in personal

Proficient performer

Neurogenic shock paradigm

Anaphylactic shock paradigm

Septic shock paradigm

Cardiogenic shock paradigm

Shock proto-paradigm

Haemorrhagic shock paradigm

Hypovolaemic shock paradigm

Conscious Decision Administer blood

Fig. 18.2  Decision-making process for the proficient practitioner

172

18  Conceptual Framework

reflection assisted by appropriate coaching that will allow the practitioner to advance to the level of proficient practitioner. The progression to proficient practitioner requires as a prerequisite engagement in the affective domain at the level of organisation. If we review the characteristics of this level it will become clear why organisation is a requirement for proficiency [3]. As values are internalised, situations arise where multiple values may be relevant. This necessitates the learner organising the values into a hierarchy that defines which are the most important. Such a system is built gradually and is subject to change as new values are incorporated. It is worthwhile reminding ourselves of the characteristic abilities of the proficient practitioner: [4]. 1. The ability to remember a sizeable set of typical specific situations (paradigms), these memories, like most memories of situations, are incomplete images, with gaps where details are irrelevant to the situation. 2. The ability to perceive the current situation as similar to one of those remembered paradigms. 3. The ability to notice when the current paradigm is no longer adequate for perceiving the current situation. 4. The ability to experience the current situation as similar to a different and more appropriate remembered paradigm, associated with each paradigm are various other paradigms which experience has taught are appropriate if the situation fails to fit the current paradigm in various ways. The hallmark of a proficient practitioner is an intuitive understanding of the paradigm they are in combined with objective deliberative decision-making. In relation to paradigms and outcomes, with experience each paradigm (or diagnosis) will be replaced by several paradigms, each of which is more specific than the original paradigm. As the refining of each situation occurs, the number of different actions suggested by specifying different sets of elements and their saliencies is progressively reduced. Likewise, the number of different sets of possible exit paradigms suggested by specifying different sets of elements and their saliencies is progressively reduced. This process sets the stage for the last stage in the refinement of the skill. The elements of the proficient stage are detailed in Table 18.4.

Expert Practitioner The degree of affective progression required to attain an expert practitioner level is considerable. It involves identifying the predominant value within one’s value system and making it an integral part of one’s life. Relatively few practitioners will be prepared to dedicate a significant part of their life to achieve expert practitioner status in clinical medicine.

Expert Practitioner

173

Table 18.4  The elements of the proficient stage Proficient practitioner PSYCHOMOTOR

EXPLICIT

TACIT

COGNITIVE

Instructional method MKO Elements Perspective Decision-making Commitment Affective domain

Tradition Reflection

AFFECTIVE

Reflection and coaching Masterclasses Context-free and situational Experienced Analytic Detached understanding and deciding. Involved in outcome. Organisation: progressing to: • The organisation of the values into a system • The determination of the interrelationships among them • The establishment of the dominant and pervasive ones Constructivist Self-directed reflection in action and reflection on action

We will not dwell too long on the acquisition of expert practitioner status as few practitioners acquire this level of attainment. The expert practitioner, on entering the resuscitation room strolls calmly over to the patient, picking up a cannula on the way and places the cannula into the second intercostal space mid-clavicular line to relieve the tension pneumothorax. When asked why they did that they reply “because it was needed”. When asked how they knew, they will pause and discuss the features and aspects of the patient’s condition which would have led to a diagnosis of tension pneumothorax, but they will not have consciously decomposed the clinical situation into these elements to come to that diagnosis. Nor will they have applied a rule, guideline or maxim (see Fig. 18.3). Expert practitioners find it difficult to explain how they do what they do as much of their performance is tacit. The elements of the expert stage are detailed in Table 18.5. As we have seen the refinement of skill involves a process of internalisation as a result of which the individual acts but cannot articulate the process by which they arrived at that action. We can explain this by suggesting that they have developed an increasing body of tacit knowledge through a process of “hardwiring” the neural pathways associated with these expert practitioner skills.

174

18  Conceptual Framework Expert performer

Neurogenic shock paradigm

Anaphylactic shock paradigm

Septic shock paradigm

Cardiogenic shock paradigm

Shock proto-paradigm

Hypovolaemic shock paradigm

Haemorrhagic shock paradigm

Administer blood

Fig. 18.3  Decision-making process for the expert practitioner

Table 18.5  The elements of the expert stage Expert practitioner

TACIT

Instructional method MKO Elements Perspective Decision-making Commitment Affective domain Reflection

Self-reflection Self-reflection and other expert practitioners Context-free and situational Experienced Intuitive Involved Characterised by value or value complex Mostly just acts but when circumstances dictate reflection in action and on action

References

175

This process can only occur as a result of acquiring a large body of concrete experience. The advantage of internalisation is that the execution of the skill becomes faster and more fluent as the need to consciously work out what the situation is and what action to take is superseded.

Summary In summary medicine is a science-based craft acquired through apprenticeship within a predominantly constructivist learning environment. Professional training and development  is a continuum which can be mapped to the five stages of the Dreyfus and Dreyfus model of skill acquisition. For most professions the large volume of factual knowledge to be acquired before commencing practial training requires an additional primer stage to be undertaken before the novice student starts practical training. Primed with the explicit knowledge base required to commence practical training the student/practitioner then needs to develop a deep body of tacit knowledge through extensive concrete experience. To succeed the student/practitioner requires the level of affective engagement, more knowledgeable other, reflective strategy and assessment/ appraisal system appropriate to their stage of professional development.

References 1. Benner P. From novice student to expert practitioner: Excellence and power in clinical nursing practice. New Jersey: Prentice Hall; 2000. p. 14–5. 2. Polanyi M. The tacit dimension. London: Routledge; 1967. p. 5–6. 3. Krathwohl DR, Bloom BS, Masia BB. Taxonomy of educational objectives: the classification of educational goals. Handbook II: the affective domain. New York: David McKay Company; 1964. p. 182–3. 4. Dreyfus SE, Dreyfus HL. The scope, limits and training implications of three models of aircraft pilot emergency response behavior. Unpublished report supported by the Airforce Office of Scientific Research (AFSC), USAF [Grant AFOSR-78-3594], University of California at Berkeley; February 1979. p 3–4.

 ppendix: The Diligent Librarian Model A for the Structure of Knowledge

This model serves to explain the origins and structure of knowledge. It is based on the model of memory discussed previously (see Diagram 1). The library has a delivery door where newly published books are continually being delivered. Newly delivered books are displayed. If they are not required they are returned to the delivery van. The diligent librarian manages the library which includes delivering books to the desk of the user and moving books between the shelves and stack. The user can have only seven books on their desk at any one time. If they want a new book and their desk is full the librarian will move one or more books from their desk to the shelves to make room. The librarian moves books directly from the display to the shelves if the user does not want them but the librarian feels that they will be useful because they relate to existing collections of books (See Diagram 2).

Visio-spatial Scratch Pad

Input

Sensory Memory

Central Executive

Long Term Memory

Phonological Loop

Diagram 1  The origins and structure of knowledge © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6

177

178

Appendix: The Diligent Librarian Model for the Structure of Knowledge

Library

Delivery

Desk

Shelves

Display

Shelves

Stack

Diagram 2  The library model

Library Short Term Memory

Delivery

Long Term Memory

Desk

Shelves

Display

Shelves

Stack

Diagram 3  Long- and short-term memory

The user’s desk and the display are analogous to short-term memory. They have small capacity and books do not stay on them for long as they are replaced by other books. The shelves and stack are analogous to long-term memory. They have vast capacity and books can stay on them indefinitely (see Diagram 3). The user’s desk is analogous to the user’s conscious awareness and consists of explicit knowledge, i.e. knowledge the user is currently aware of. Only books on the user’s desk are in the conscious domain (See Diagram 4). One set of shelves holds the books that the user had on their desk which have been removed from the desk by the diligent librarian to make room for new books. The books on this shelf are analogous to internalised knowledge. They are not

Appendix: The Diligent Librarian Model for the Structure of Knowledge

179

Library Short Term Memory

Delivery

Long Term Memory

Explicit

Shelves

Display

Shelves

Stack

Diagram 4  Conscious awareness and explicit knowledge

Library Short Term Memory

Delivery

Long Term Memory

Explicit

Internalised

Display

Shelves

Stack

Diagram 5  Internalised knowledge

currently in the user’s conscious awareness as they are not on the desk, but can be brought rapidly back from the internalised shelves if they are needed and there is room on the desk. Once brought back to the desk the internalised books become explicit books (See Diagram 5). Some books are filed directly on shelves by the diligent librarian without being placed on the user’s desk. These are placed on the subliminal shelf. These books may be raised to conscious awareness by being placed on the user’s desk but this is not as straightforward as moving internalised books to the user’s desk. A special request has to be made for this analogous to the need to use special techniques to make explicit subliminal knowledge (See Diagram 6).

180

Appendix: The Diligent Librarian Model for the Structure of Knowledge

Library Short Term Memory

Delivery

Long Term Memory

Explicit

Internalised

Display

Subliminal

Stack

Diagram 6  Subliminal knowledge

Library Short Term Memory

Delivery

Long Term Memory

Explicit

Internalised

Display

Subliminal

Intrinsic

Diagram 7  Intrinsic knowledge

Some books have been in storage since the library opened and are not generally accessible to the user, even with the help of the diligent librarian. These include books on how to run the library, how the filing system works, how to regulate the heating, etc. The books in the stack are analogous to intrinsic memory (See Diagram 7). Information is available for use by the user only explicitly by being placed on the user’s desk. The user cannot directly access the internalised, subliminal or intrinsic books. The diligent librarian can access the internalised, subliminal or intrinsic books and uses them to help run the library. This means that the user has access to only a proportion of the information available to the diligent librarian (See Diagram 8).

Appendix: The Diligent Librarian Model for the Structure of Knowledge

Library Short Term Memory

Delivery

Long Term Memory

Explicit

Internalised

Display

Subliminal

Intrinsic

Diagram 8  Explicit, internalised, subliminal and intrinsic knowledge

181

Index

A Abstention, 125 Abstract conceptualization (AC), 31, 33 Accommodative knowledge, 30 Action strategies, 83 Active experimentation (AE), 31, 33 Adaptation, 46 Adaptive learning modes, 31, 32 Adaptive Style Inventory (ASI), 35–36 Affective domain, 24, 25 Anderson and Krathwohl’s knowledge dimension affective domain, 24, 25 cognitive dimension, 19, 20, 22 conceptual knowledge, 19 explicit knowledge, 23 factual knowledge, 19 metacognitive knowledge, 19 psychomotor domain, 25, 26 Appraisal Good Medical Practice Framework, 70, 71 medical appraisal guide model, 70 Apprehension-extension (CE-AE), 33 Apprehension-intention (RO-CE), 33 Aptitude, 47 Aristotle, 6 Aspects, 161, 162 Assessment blueprint, 67 defensible assessment, 67, 68 definition, 65 Miller’s framework, 68, 69 norm and criterion referenced assessment, 66 requirements of, 66 types of, 67 Assimilative knowledge, 30 Assumptions, 138

B Beliefs, 5, 151 false belief, 6 justification, 9, 10 true beliefs, 6 Bloom’s taxonomy of cognitive domain alignment of edcational objectives, instructional methods and assessment, 18 comprehension, 17, 18 intellectual abilities and skills domain, 16–18 knowledge domain, 16, 17 Brain plasticity, 39 Bruner, Jerome, 45 C Capable/capability, 131 Characteristics of model I behaviour, 85–86 Characteristics of model II behaviour, 86 Chunk capacity, 41 Codifiable tacit knowledge, 108 Cognitive dimension, 19, 20, 22 Collective tacit knowledge, 77, 78 Competence, 132, 136 adequacy, 62 knowledge, skills and attitudes, 62 and performance, 62 psychological motivator, for learning, 62 Competent practitioner, 130, 165–172 Complex groups of conditions, 105 Complicated conditions, 105 Comprehension-extension (AC-AE), 33 Comprehension-intention (RO-AC), 33 Comprehensive entities, 100–102 Conceptual framework, 104

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020 D. Burke, How Doctors Think and Learn, https://doi.org/10.1007/978-3-030-46279-6

183

Index

184 Conceptual knowledge, 19 Concrete experience (CE), 31, 33 Consequences, 83 Constructivism, 81 cognitive constructivism, 44 definition, 43 social constructivism, 44 Context dependant, 162 Contingent variables, 139, 143, 152 Convergent knowledge, 30 D Decision making process, 168, 171, 174 Divergent knowledge, 30 Dualism, 103 E Emotional response, 161, 164 Empiricism and rationalism, 7–8 Enhanced appraisal, 69–72 Epistemology, 99 Eraut’s routinisations, 47, 127 Experiential leaning theory (ELT) accommodative knowledge, 30 adaptive learning modes, 31 assimilative knowledge, 30 convergent knowledge, 30 divergent knowledge, 30 learning flexibility, 35–36 learning style inventory, 33, 34 prehension dimension, 29 second order learning strategies, 34 third order learning strategy, 34 transformation of experience, 29, 30 Expert practitioner, 55, 172, 173 Explicit knowledge, 13, 107, 110, 115–117 F Facial recognition, 75 Facilitated learning, 162 False beliefs, 6, 150 First order learning strategies, 33 Fit practice to theory, 45 Fit theory to practice, 46 Formative assessment, 65 Framing, 90–92 G Gestalt psychology, 103 Goals, 143 Governing variables, 82, 138, 140

H Hardwiring and tacit and explicit knowledge, 115–118 Hermeneutic cycle, 104 Herzberg’s hygiene and motivational factors, 139, 140 I Iinteriorisation, 76 Illustrative test items, 17 Interiorisation, 76 Internalised tacit knowledge, 34, 110 Intrinsic tacit knowledge, 111 J Jonassen’s general characteristics of constructivist learning environments, 46 Justification, 9, 10 K Knowledge explicit knowledge, 13, 110, 115, 116 internalised, subliminal and intrinsic knowledge, 118 internalised tacit knowledge, 110 intrinsic tacit knowledge, 111 practical knowledge, 12 processing of data, 12 source domains, 112–115 subliminal tacit knowledge, 110 tacit, 13 technical knowledge, 12 utility/actionable outcomes, 113 L Learning, 39 Learning flexibility, 35–36 Learning style inventory, 33 Long term memory, 40, 41 Logic, 11 M Maslow’s Hierarchy of needs, 139 Mastery and practical wisdom, 55 Medical appraisal guide (MAG) model, 70 Memory, 126, 127 long term memory, 40, 41 short term memory, 40, 41 working memory, 40, 41 Mental schemas, 45

Index Metacognitive knowledge, 19 Metacognitive reflection, 150 Modern teaching technology, 162 Modified structure of theory of action, 140 More Knowledgeable Other (MKO), 44, 159 Movement sensors, 11 Multi-source feedback (MSF), 153 N Needs, 138 Nine learning styles and four dialectic tensions, 34–35 Norm, criterion-referenced and ipsative assessment, 66 O Objectivism and constructivism, 43–44 Ontology, 99 P Performance, 130 Piaget, Jean, 45 Piaget’s schema, 46, 104, 45 Piaget’s schema’s revisited, 124–126 Plasticity, 39 Polanyi’s model of tacit knowledge, 75–77 Positivism, 102 Practical knowledge, 12 Procedural knowledge, 19 Professional knowledge applied science component, 3 basic science component, 3 medical curriculum, 3 skills and attitudinal component, 3 Professional practice, 3, 4, 47, 56, 71, 89, 90, 94, 118, 134, 157 Professional skill, 124 Proficient practitioner, 53, 54, 169–172 Progression of the components of the Dreyfus and Dreyfus model, 56–57 Psychomotor domain, 25 Psychomotor skill, 115 R Reason and rational thinking, 10–11 Reflection, 104 action-outcome cycle, 146–148 consciously/subconsciously reflection, 143 contingent variables, 143, 144, 152, 154 definition, 89 Gibbs model, 92

185 governing variables and needs and beliefs, 143, 144, 150, 154 Johns’ model, 93 needs and validity, 151 perspective of situation, 149 reflection-in-action, 89–91 reflection-on-action, 90 role of, 89 sub-conscious recognition, 145 theories in use, 152–153 Reflection-on-action, 90 Reflective observation (RO), 31, 33 Reframing, 91, 92 Relational tacit knowledge, 77 Role of the teacher in skill acquisition, 56 Rotation sensors, 11 Routinisations, 104 S Second order learning strategies, 34 Sense receptors, 11 Short term memory, 40, 41 Skill, 121 capable/capability, 131 competence, 130, 134 competency, 130 competent, 130 definition, 122 development and refining of, 123 Dreyfus model, 132 Miller’s framework and modified Miller’s framework, 133 performance, 131 professional skill, 122 Skill acquisition advanced beginner, 51 affective domain, 158 cognitive attainment characteristic, 157 competent practitioner, 52, 53 comprehensive taxonomy, 128 developmental stage of, 158 Dreyfus model of, 49, 157 element recognition, 57 expert practitioner, 55 memory, 126, 127 novice, 51 proficient practitioner, 53, 54 psychomotor skill acquisition, 128, 130 role of teacher, 56, 57 salience recognition, 57 situation recognition, 57 stages, 49 Skill set, 122–124 Social constructivism, 44, 46

Index

186 Somatic tacit knowledge, 77 Subliminal tacit knowledge, 110 T Tacit knowledge, 13, 104, 165 cognitive perspective, 108 Collins Relational Tacit Knowledge, 107 Collins’ taxonomy, 77, 78 explicit knowledge, 108 facial recognition, 75 proximal and distal, 75, 76 and tacit knowing, 118 Technical knowledge, 12 Theories of action diagrammatic model of, 135 Maslow and Herzberg’s models, 141 Theories-in-use action strategies, 83 consequences, 83 definition, 83 first order constancy, 84 governing variables, 82

micro-theories, 83 model I and model II behavior, 85, 86 second order constancy, 84 single and double loop learning, 84 A third model of reflection, 94 Third order learning strategy, 34 True belief, 6 Truth, 6 V Values, 138 Vygotsky, Lev, 44 W What we reflect on, 143–145 Working memory, 40, 41 Z Zone of Proximal Development (ZPD), 44, 159