Response to the 2011 Question of the Year
Dr. O'Brien is assistant professor, Department of Medicine and Office of Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California.
Dr. Teherani is associate professor, Department of Medicine and Office of Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California.
Correspondence should be addressed to Dr. O'Brien, University of California, San Francisco, School of Medicine, 185 Berry St., Suite 5350, Box 3202, San Francisco, CA 94143-3202; telephone: (415) 519-7935; e-mail: firstname.lastname@example.org.
Workplace learning is both the blessing and the curse of medical education. The extended period of practical, apprenticeship-type training that occurs in medicine is the envy of educators in other professions. In the language of Lave and Wenger's1 communities of practice, this lengthy period of workplace learning allows trainees (“newcomers”) to learn by working alongside experienced practitioners (“old-timers”), such that trainees gain substantial, relevant experience and skills, are up-to-date with systems and norms of practice, and demonstrate competence before beginning unsupervised practice. If the goal of medical education is to train learners to function effectively in current systems and workplaces by replicating the practices of old-timers, then our existing model of workplace learning works relatively well. If, on the other hand, the goal is to train practitioners to deliver optimal patient care, then maintaining the status quo is undesirable, and we must identify ways of using workplace learning to facilitate changes that will improve current systems and better the health of patients.
Below, we discuss two different ways that change can occur through workplace learning. The key to both is recognizing clinical practice and learning environments as one and the same. Too often, the two are treated as independent entities, resulting in missed opportunities to engage and incorporate trainees into change processes as leaders, active participants, and/or partners.
Learner-driven change: Rapid growth and evolution in technology, clinical science, and health services research leaves individual practitioners and clinical practices struggling to keep up. Meanwhile, medical students and residents learn cutting-edge knowledge and skills through formal curricula and simulation; they regularly use technologies and online resources to access and evaluate information in real time, and they are trained to work with data and patient registries to assess their own practice and conduct quality improvement projects. Often, this experience results in newcomers entering clinical environments equipped with advanced knowledge and skills that are not used in practice settings but that are needed and valued by old-timers to improve care for patients and populations. These circumstances create opportunities for an exchange between trainees and established practitioners that is bidirectional rather than unidirectional. Rather than relying entirely on the old-timers to teach them the tricks of the trade, trainees have tricks of their own to share. This fundamental reconceptualization of the teacher–learner relationship empowers learners in a way rarely seen in medicine and, thus, requires a major shift in entrenched hierarchies, beliefs, and practices. It requires explicit attention to the role of learners as change agents so that change is normalized and integrated into daily practice, and the clinical workplace becomes a place in which newcomers and old-timers habitually learn from each other.
Mandate-driven change: In the last decade, concerns about quality of care and patient safety have given rise to institutionally mandated changes to practice, such as clinical protocols to guide processes of care, checklists to reduce the likelihood of error, and the restructuring of service delivery to improve coordination and access to care. Many of these efforts are top-down and focus on changing the work environment and improving patient care solely through the practice of old-timers. Consistent with the apprenticeship model, practitioners learn the changes, routinize them, and ultimately pass them along to newcomers through modeling and reinforcement. This method leaves the conventional role of the old-timers intact and, to the extent that old-timers have been passive recipients rather than active agents in the change process, risks missing a valuable opportunity to engage trainees. From the trainees' perspective, the “new way” is simply “THE way that things are done,” with little appreciation for the vision, leadership, negotiation, training, and reinforcement that it takes to make even small changes in practice. Many of the changes that occur through mandates yield significant improvements in patient safety and health but underutilize the learning environment. Explaining the goal or rationale underlying protocols and checklists to trainees and using these initiatives to instill a commitment to ongoing improvement in patient care are ways that the mandate-driven change process can better connect education and practice improvement.
Workplace learning is powerful and must be carefully orchestrated to yield the desired learning and patient outcomes. We described two change processes that have workplace learning at the core. Each has strengths and limitations—limitations that can be overcome by addressing the relationships between old-timers and newcomers, recognizing clinical practice and learning environment as tightly linked entities, and aligning change efforts accordingly. In environments in which trainees are invited into the change process, workplace learning can lead to optimal learning that advances our efforts to improve the health of patients and populations.
The authors wish to thank Louise Aronson, MD, Sandrijn Van Schaik, MD, Patricia O'Sullivan, EdD, and David Irby, PhD, for their thoughtful feedback on this essay.
1 Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge, Mass: Cambridge University Press; 1991.