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Academic Medicine:
doi: 10.1097/ACM.0b013e318238e069
Graduate Medical Education

Theory and Practice in the Design and Conduct of Graduate Medical Education

Hodges, Brian David MD, PhD; Kuper, Ayelet MD, DPhil

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Author Information

Dr. Hodges is professor, Department of Psychiatry, Faculty of Medicine, and Department of Theory and Policy Studies, Ontario Institute for Studies in Education, University of Toronto; director, scientist, and Richard and Elizabeth Currie Chair in Health Professions Education Research, Wilson Centre for Research in Education, University Health Network/University of Toronto; and vice president for education, University Health Network; all in Toronto, Ontario, Canada.

Dr. Kuper is assistant professor, Department of Medicine, Faculty of Medicine, University of Toronto; scientist, Wilson Centre for Research in Education, University Health Network/University of Toronto; and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre; all in Toronto, Ontario, Canada.

Correspondence should be addressed to Dr. Hodges, 190 Elizabeth St., R. Fraser Elliott 1-410, Toronto, Ontario M5G 2C4, Canada; telephone: (416) 340-3079; e-mail: brian.hodges@utoronto.ca.

First published online October 28, 2011

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Abstract

Medical education practice is more often the result of tradition, ritual, culture, and history than of any easily expressed theoretical or conceptual framework. The authors explain the importance and nature of the role of theory in the design and conduct of graduate medical education. They outline three groups of theories relevant to graduate medical education: bioscience theories, learning theories, and sociocultural theories. Bioscience theories are familiar to many medical educators but are often misperceived as truths rather than theories. Theories from such disciplines as neuroscience, kinesiology, and cognitive psychology offer insights into areas such as memory formation, motor skills acquisition, diagnostic decision making, and instructional design. Learning theories, primarily emerging from psychology and education, are also popular within medical education. Although widely employed, not all learning theories have robust evidence bases. Nonetheless, many important notions within medical education are derived from learning theories, including self-monitoring, legitimate peripheral participation, and simulation design enabling sustained deliberate practice. Sociocultural theories, which are common in the wider education literature but have been largely overlooked within medical education, are inherently concerned with contexts and systems and provide lenses that selectively highlight different aspects of medical education. They challenge educators to reconceptualize the goals of medical education, to illuminate maladaptive processes, and to untangle problems such as career choice, interprofessional communication, and the hidden curriculum.

Theories make visible existing problems and enable educators to ask new and important questions. The authors encourage medical educators to gain greater understanding of theories that guide their educational practices.

Theories provide complex and comprehensive conceptual understandings of things that cannot be pinned down: how societies work, how organizations operate, why people interact in certain ways.

Reeves et al1

Medical education practice is more often the result of tradition, ritual, culture, and history than of any easily expressed theoretical or conceptual framework. In this article, we explain the importance and nature of the role of theory in the design and conduct of graduate medical education, and we outline three groups of theories relevant to graduate medical education: bioscience theories, learning theories, and sociocultural theories.

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What Is Theory?

Theory is like gravity: profoundly linked to our experience of life, but also more conceptual than material and therefore not directly visible. Gravity has been present throughout human existence, but it was not until Newton described gravitational theory that humans had a conceptual language to discuss its nature and use. Gravity was, of course, used in practice long before it was formulated in theoretical terms. However, only with the advent of scientific theory could an in-depth understanding of gravity be harnessed for research and development.

Theories of many kinds play a role in medical education and practice. Yet, as with gravity prior to Newton, practice in medical education is more often the result of tradition, ritual, culture, and history than of any easily articulated theoretical or conceptual framework. Practices are reproduced and passed down without being anchored to theories that explain why certain approaches lead to effective education. The rise of formal studies in medical education, with burgeoning research, journals, and international conferences, raises new questions about the relationship between theory and practice in this field.

In medical education, as in other scientific fields, there is the promise of improving practice by basing it on theory and evidence. Bordage2 has argued that all research and development in medical education should be based on a theoretical framework. However, there is a risk of developing an artificial split between theory and practice—relegating the former to ivory tower theoreticians and the latter to in-the-trenches practitioners. Albert and colleagues3 argue that knowledge generation based on theory can serve both researchers and practitioners but that the nature and control of knowledge generation, its funding, and the format and dissemination of the resulting knowledge differ depending on the intended audience. Stokes,4 in Pasteur's Quadrant, suggests that research should emphasize both the development of theory and the use of new knowledge to improve practice. Pasteur's own research simultaneously led to the development of germ theory and to the means to pasteurize milk. It is in this spirit that we wrote our article: to explore the relationship between theory and practice in a way that advances both theoretical understanding and the effectiveness of practice for an audience of educators (including clinical teachers, administrators, and researchers) interested in graduate medical education. To accomplish this aim, medical educators must pay greater attention to their theory literacy so that they can articulate continuously the link between theory and practice.

Many terms could be used to frame this discussion; in the first few paragraphs above, we have employed several of them. Terms such as theory, conceptual framework, epistemology, and paradigm have different but related meanings, as do the words practice and praxis. However, we have left aside discussion of these terms' nuanced meanings and deliberately lumped them together to improve accessibility for the nonspecialist reader. We have used theory to represent what Reeves and colleagues1 have called a complex and comprehensive conceptual understanding of how things work. Similarly, we use have used practice to represent doing—teaching, learning, creating, interacting, leading, governing, and all the other activities that collectively make up education. The interested reader can find a more detailed glossary of these terms in one of our previous publications.5

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What Kinds of Theories Are Useful to Graduate Medical Education?

Far from being ivory tower concepts debated by armchair theorists at great remove from “real” clinical and educational settings … theories are very useful ways to analyse the nature of medical schools and the roles people play within them, in the service of imagining and enacting anything from a minor change to a radical reform.

Kuper and Hodges6

There are hundreds of theories. They range from local to global, from small scale to large. There are grand theories and circumscribed theories, theories tied to disciplines (economics, sociology, biology, physics), to approaches (critical theory), and to schools or movements (psychoanalysis, Marxism). There are popular theories, discredited theories, overapplied theories and little-known theories. In preparation for this article, we reviewed the literature on theories of medical education. Searching appropriate databases with the terms theory and medical education yielded diverse abstracts illustrating the enormous breadth of the existing literature. Approaching theory in this way, however, would be daunting for a medical educator. Consequently, in this article we have presented a few broad groups of theories that are useful to discussions of graduate medical education.

For the purposes of this discussion, we have classified theories into three large groups: bioscience theories, learning theories, and sociocultural theories. Table 1 presents a list of theories, clustered by theory type, and provides comments about their application to graduate medical education. In the bioscience cluster, theories arising directly from neuroscience, kinesiology, and even genetics have relevance for medical education because of their focus on how the human brain learns. At the other end of the spectrum, sociocultural theories from sociology, anthropology, economics, and other disciplines provide useful perspectives on why we have medical schools at all and how they function vis-à-vis the larger societies in which they operate. Our divisions between these clusters are not sharp; clustering theories at all is simply a shorthand way of helping readers understand differences in theories' history and nature. For example, although we have located cognitive psychology within the biosciences, it is commonly used as a foundation for many learning theories. Other areas of psychology, such as social psychology, draw on broad social perspectives and, thus, could be classified under sociocultural theory. Our groupings are simply a means of organizing a very large range of theories for the purpose of approaching a daunting body of literature, not a coherent conceptual framework of its own.

Table 1
Table 1
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Bioscience Theories: Powerful, Often Taken for Granted

Theories arising from bioscience are the most familiar to medical educators because medicine itself has long given priority to biomedical models of practice and research. Bioscience theories—theories arising in disciplines focused on the biological substrate of life (e.g., biochemistry, genetics, neuroscience)—are so familiar that it is easy to forget that they are theories, not truths. It is often only when one long-held understanding is displaced by another that the theoretical, and therefore tentative, nature of bioscience theories becomes visible. Famous examples of this include the shift in the accepted etiology of gastric ulcer disease from stress to bacteria, the rejection of the notion of parenting style causing schizophrenia in favor of the dopaminergic hypothesis, and the discredited aluminum theory of Alzheimer disease. A great majority of the developments in medicine that we believe to be true are actually based on theoretical assumptions and imperfect evidence that may be swept away by new research leading to more explanatory theories.

Because bioscience approaches are so dominant in medicine, they are not often articulated as theories per se. The pervasiveness of such “theories” can lead to the impression that no particular theory is being used. Thus, physicians and medical educators sometimes have difficulty identifying the nature of theory itself.7 The social sciences have a stronger tradition of explicitly articulating what theory is, debating which theories are relevant to which contexts and questions, and studying the history and evolution of theory itself. Social scientists therefore have more experience in thinking about the role and utility of different theories. If we in medical education follow this approach and think about the theoretical basis of bioscientific knowledge, we can gain a deeper understanding of the utility of theory for medical education.

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Bioscience Theories and Medical Education

… there have been numerous books, journal articles, policy studies, and stories in the media about how our emerging understanding of brain development and neural function could revolutionize educational practice.

Bruer8

Fundamental bioscience theories arising from domains such as biomolecular medicine and genetics may initially seem to offer little to medical education. However, it is striking how often the concept of genetic determinism is applied to discussions about medical school and residency admissions, wherein endless debates occur about attributes appropriate for medical education and practice. These arguments are sometimes based on notions of fixed, inherent, and presumably genetic human characteristics. A study by Garfinkel and colleagues,9 for example, rooted in the presumed existence of biologically determined personality traits, looked at the relationship within a group of psychiatrists between their levels of sociopathy (as measured by the Minnesota Multiphasic Personality Inventory) and their later sexual abuse of patients. The authors found that, although certain traits may be associated with unprofessional behavior, the influence of context was so strong that trying to base decisions on predetermined traits risked unethical practices. Whereas links between personality and later behavior can be shown in many domains, and although genetic determinants of human behaviors undoubtedly exist, environmental contexts shape behaviors to such an extent that genetic contributions alone cannot be isolated. Thus, although biological, genetic, and other deterministic theories have relevance to complex behaviors, their tacit use in the admission process belies the importance of context; they are probably, for the moment, a bridge too far to be useful for medical education.

Neuroscience, by contrast, offers useful theoretical notions for education. A recent review of the neurobiology of learning provides glimpses of how neuroscience might influence medical education.10 LeBlanc,11 for example, looks at how activation of the hypothalamic– pituitary axis during stress in simulated learning environments significantly affects everything from drug dose calculations to decision making and collaboration. Here, concepts from neurophysiological theory have propelled a program of research with implications for medical education ranging from the effectiveness of learning in a simulated environment to understanding how clinicians interpret a complex situation as either a threat or a challenge.12 Similarly, emerging neuroscience theory about attention and memory formation has contributed important understanding of how students work with, represent, and retain information during learning. Recent research, for example, has cast doubt on multitasking—something almost ubiquitous in clinical settings—being adaptive in relation to memory formation.13,14

A third area in which bioscience theory has been applied to medical education arises from kinesiology. Research by Walsh and colleagues15 and Brydges and colleagues,16 for example, draws on theories of motor control to understand motor learning in technical skills. Theories from basic motor learning have been used to inform the design of regimens for acquiring technical skills. For example, Fitts and Posner's17 model of automaticity and skill expertise has long dominated the literature of surgical education. Ericksson and colleagues'18 notion of deliberate practice and expertise has served as the basis for the development of simulation programs and of competency-based curricula; more recently, Guadagnoli and Lee's19 challenge-point framework has influenced thinking about model fidelity in simulated settings increasing in tandem with growing expertise.

Since the 1950s, many psychologists and psychometricians have joined the ranks of medical schools. From early on, these researchers engaged in significant advocacy to legitimize their expertise and their importance to medical education.20 This may be one of the reasons that psychological theories have arguably had the most dominant presence of all bioscientific theories in medical education. For example, there is a long history of studying cognitive decision making, including how knowledge is structured for learning, recalled later, and employed in practice. Research programs such as those of Patel and colleagues,21 Norman and colleagues,22,23 Dolmans and Schmidt,24 and many others build on cognitive psychological theories and have widely influenced the design of medical education and the choice of pedagogical approaches—one famous example being the published debate between Colliver25 and Norman and Schmidt26 about the theoretical basis (or lack thereof) for problem-based learning. Theories from cognitive psychology continue to offer important foundations for the design of educational courses, programs, and tools. For example, Gruppen27 summarized the implications of cognitive theory for ambulatory care education, underscoring the importance of context in learning, the need for students to have “transferable knowledge” to function in ambulatory settings, the importance of balancing depth and breadth of knowledge, and the role of prior knowledge in diagnostic decision making and problem solving.

The emergence of multimedia technologies has led to the growth of new theoretical research in a branch of cognitive psychology that studies conceptual models of learning. For example, the cognitive theory of multimedia learning posits that people learn differently from words than from pictures because there are separate channels for processing these two different kinds of inputs. Because the capacity to process information in working memory is limited, meaningful learning requires appropriate cognitive processing that includes both textual and visual images. Mayer28 provides nine evidence-based approaches to guide the design of multimedia learning materials and resources in line with this theory. At a time when graduate medical education is enthusiastically embracing myriad Web-based approaches, including e-learning, social media, and handheld devices, it is particularly important to ensure that the use of these tools is grounded in theory and not simply driven by enthusiasm (or marketing pressure) for new technologies and gadgets. van Merriënboer et al,29 as well as several other authors,30,31 use cognitive load theory to understand how to design educational programs and materials, in particular those using multimedia and simulation. van Merriënboer et al developed guidelines for instructional design based on this theoretical model of human cognitive architecture that implies that learners cannot attend to too many sources of stimuli at one time and that the goal of education (particularly simulation training) is to automate some cognitive and motor processes to increase learners' available attention and, therefore, cognitive and motor ability.29 Kurahashi et al32 have applied the theory of cognitive load to problems in simulation-based training of technical and other skills.

Although debates about the effectiveness of various modes of learning are rarely couched in biological terms, the effectiveness of various kinds of media (including social media), classroom approaches, and testing methodologies can be approached through the lens of bioscience, building on theories about how the brain functions. While it is certain that many new technologies will be implemented in graduate medical education, Carnahan and colleagues33 have underscored the importance of asking theory-driven questions about the utility of new approaches and testing new educational models experimentally rather than simply trying out untested approaches in educational settings and then evaluating their use in practice.

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Learning Theories: Common, Useful, Variable Evidence Base

Clinical effectiveness and efficiency in medicine for patient benefit should be grounded in the quality of medical education. In turn, the quality of medical education should be informed by contemporary learning theory that offers high explanatory, exploratory and predictive power.

Bleakley34

Learning theories are popular and useful for medical education generally and for graduate medical education specifically. Such theories emerge from a range of different disciplinary traditions, primarily psychology and education. Mann35 has recently published a helpful overview of learning theories commonly applied to medical education. Her review focuses on learning theories in five categories: behaviorist, cognitivist, humanist, social, and constructivist. We recommend Mann's classification to those interested in this area.

Although learning theories are widely employed, their evidence bases are not equally robust. Some seem to operate more as metaphors about learning than as true theories. Norman36 has sharply critiqued one of the most commonly cited learning theories: adult learning theory.

Adult learning theory, first described by Malcolm Knowles in the early 1970s, is based on a number of apparently self-evident axioms about how adults learn. The fundamental assumptions remain largely untested, and a critical analysis suggests that they may be largely a product of the environment in which adults find themselves rather than of any innate differences between adults and children…. Uncritical reliance on the principles of adult learning may have detrimental consequences, particularly in the domain of maintenance of competence.

Eva and Regehr,37 among others, compare several different theories in an effort to understand why self-assessment and self-direction—the central constructs at the heart of adult learning theory—are problematic in many studies. Simply put, self-assessment and self-direction seem not to be evidence-based constructs. By contrast, notions such as self-monitoring38 and directed, self-guided learning39 rest on a stronger theoretical base and therefore have greater promise for the design and assessment of graduate medical education. The nature and function of the related notion of feedback, another ubiquitous but undertheorized construct in medical education, is also beginning to be explored. For example, theory-based research has shown robust differences related to the timing of the provision of feedback and its variable effects on learning.40

In her review, Mann35 argues that too much attention has been focused on learners as individuals, noting that the most robust learning approaches are based on theories that view learning as “intimately tied to context and occurring through participation and active engagement in the activities of a community.” She highlights social cognitive theory and situated learning theory as strong bases on which to design medical education. Within these theories, the notion of legitimate peripheral participation provides a way of understanding how learners move from the periphery of a practice community (as observers of professional activity) to more central participation and responsibility. These theoretical perspectives direct attention away from the assessment of decontextualized individual traits and toward analyzing learner behaviors and participation in practice settings. The emphasis is on collective learning, not only in groups or teams but also by whole institutions. Weaving together the outcomes of educational programs with those of health care institutions requires measures well beyond the assessment of knowledge on written tests or of skills on an objective structured clinical examination. Rather, the important indicators of learning at an institutional level are patient outcomes and other systems-level indicators. For graduate medical education, the implication is that teaching and assessing students based on lists of decontextualized skills and areas of knowledge are less important than focusing on residents' learning and the evolution of residents' competence in actual practice settings. For example, the work of Kennedy and colleagues41 on progressive independence uses several different theories to explore this crucial but generally taken-for-granted aspect of learning in health care institutions.

Similarly, Kneebone42 has marshaled learning theory to purposefully design simulation-based learning in technical domains. Kneebone argues, on the basis of theoretical research, that simulations should allow for sustained, deliberate practice in a safe environment, that recently acquired skills must be consolidated within a defined curriculum that includes regular reinforcement, that simulations should include access to expert tutors, and that simulations should map onto real-life clinical experience. The implication is that simulation in graduate medical education should be neither an add-on nor an entirely self-directed activity but, rather, must be thoughtfully and systematically embedded in the design of both learning and practice. The lack of a theoretically informed approach to most simulation training may help to explain emerging findings of failure to learn in simulated environments.43

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Sociocultural Theories: Underused, Complex, Valuable

Social science theories can be used to explore how particular modes of medical education are constructed, examine unexplored assumptions about their nature and function, and make visible implications and adverse effects of the way they have come to be.

Kuper and Hodges6

Many medical educators today are making good use of learning theories to provide context for their research and to recommend educational program design. However, in another article reviewing the use of theory in continuing medical education, Mann44 asks a challenging question: How much has educational theory helped us? She argues that the answer is mixed; in some instances, theory has indeed been helpful to inform educational practice. At the same time, a great deal of theoretical work has been difficult to apply or has proved to be of questionable validity (as with adult learning theory). She notes that “an emerging area of theory that may hold great opportunity for practitioners … comes from anthropology and sociology and the study of sociocultural learning.”44 Similarly, Bleakley45 argues that a mismatch exists between the broad range of theories offered in the wider education literature and the relatively narrow range of theories that have been privileged in medical education. He suggests, like Mann, that currently dominant learning theories are limited in that they address how individuals learn, yet fail to explain how learning occurs in “dynamic, complex and unstable systems such as fluid clinical teams.”45 We agree with Mann's and Bleakley's assessments and suggest that it is important for postgraduate medicine to look to sociocultural theories, which by their nature are concerned with context and systems.

Sociocultural theories have been, until recently, largely unknown to medical educators. Researchers outside medicine have sometimes studied medical education using such theories, which produced, for example, classic medical sociology texts about acculturation in medical school by eminent sociologists like Becker and colleagues46 (Boys in White) and Merton and colleagues47 (The Student–Physician), who were not themselves engaged in medical education. Medical educators themselves, however, have rarely known enough about sociocultural theories to enable such theories' application to the development of medical education. This is now changing as sociologists, anthropologists, political economists, and others with expertise in the social sciences and humanities are entering the field of medical education research, bringing with them a wide variety of perspectives, approaches, and theories from their home disciplines.

At first glance, such theories and perspectives, which often address large-scale societal questions, may seem vague and distant from the practical concerns of clinical teachers. However, sociocultural theories can be intensely practical. They can provide lenses that selectively highlight different aspects of medical education, allowing each to be addressed in turn. For example, some theories call attention to structural issues, enabling a close examination of the positive and negative effects of legislative or policy contexts and constraints on medical education. Others hone in on social relations between and within groups, exposing to scrutiny the cultural, social, or interpersonal aspects of medical education. Many such theories are critical, which means that they highlight the effects of power, bringing attention to inequities that might otherwise go unnoticed. Sociocultural theories make certain previously invisible things visible; newly visible problems can then be studied, and newly visible solutions can be implemented.

Sociocultural theories can, in this way, eventually lead to a wholesale reimagining of medical education. In Medical Education for the Future: Identity, Power, and Location, for example, Bleakley and colleagues48 use several critical theories to argue that medical education as a practice must be reoriented toward a patient-focused, democratic future. They contend that the staunchly individualistic hero–doctor is no longer the professional ideal; rather, the purpose of medical education is to develop medical professionals who can participate in dispersed social networks that form and reform to accomplish clearly defined health care tasks. They describe how modernist, sterile, and sequestered classrooms should be replaced by flexible, human-scale spaces embedded in the complex messiness of real-world health care. Further, they suggest that the artificial separations of classroom and clinic and of simulated and real experiences should be dissolved.

The implications for graduate medical education are significant. Although new competency frameworks in the United States and Canada emphasize roles beyond medical expertise, Bleakley and colleagues'48 analysis suggests that fostering such competencies as collaboration, communication, advocacy, and systems-based practice should be embedded in real workplaces and not sequestered in academic half-days and classroom learning environments. Furthermore, learning about these dimensions of competence makes visible such entities as social networks, team dynamics, and the changing role of doctors and other health professionals in society. Bleakley et al highlight the particular utility of such theories as actor network theory and cultural-historical activity theory and how these approaches can be used to reconceptualize the goals of medical education.

Sociocultural theory can also be used to ask very pragmatic questions about medical education. For example, feminist and antiracist theories, which make visible the inequities due to gender, religion, race, and/or sexual orientation, have a great deal to offer for understanding and addressing one of graduate medical education's biggest problems: the hidden curriculum.49–51 Although a student can be prepared for excellent communication, collaboration, empathy, and patient-centered attitudes through years of formal training, just a few minutes in a work environment that does not model these behaviors will rapidly lead to their extinction in the student's behaviors. We may teach residents to respect other health professionals in a simplistic way, but if they are never exposed to thinking about the power disparities, hierarchy, and boundary struggles that exist between professions, they will have no way of interpreting, much less coping with or ameliorating, these dynamics in the workplace.52 Thus, using sociocultural theories to decode toxic learning environments (something often unearthed during accreditation processes) can illuminate maladaptive practices and the hidden curriculum.

The perspectives of certain iconic sociocultural theorists also make it possible to untangle specific problems faced in graduate medical education. For example, Bourdieu's social capital theory could be used to better understand the differences and competitiveness of medical schools and residency programs in terms of attractiveness to applicants, reputation, and admission rates.53 Neo-Marxist theories, which focus on capital and class structures, could be used to understand connections among remuneration, practice patterns, and—of great concern to postgraduate education—career choice.54 Foucault's theory of discourse and his notion of normalization bring to light (and thus allow to be addressed) the constraints on what it is possible for a student or teacher in educational and health care institutions to say, think, and be. For example, a Foucauldian perspective has been used to study how power operates in objective structured clinical examinations, where pseudoempathy can emerge,55 and to grapple with the implications of using physicians as opposed to standardized patients as examiners.56

At the level of social relations, Bakhtin's57 theories of language and his notion of utterance, and Smith's58 theorizing of the intersubjective creation of meaning, offer approaches to understanding and teaching interpersonal communication, including communication within patient–physician and/or trainee–consultant dyads. These sociocultural theories can help us understand why training in interprofessional communication and team-based collaboration, for example, frequently fails. Although pragmatic communication skills or collaboration skills may be learned, if the forces of professional hierarchy, power differentials, and identity are ignored the skills may never be employed, or, worse, the very opposite of the intended pedagogy may be conveyed as a hidden curriculum.

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Putting Theory to Work in Graduate Medical Education

Theory can help people move beyond individual insights gained from their professional lives to a situation where they can understand the wider significance and applicability of these phenomena. Good theory based research is immediate, insightful, and applicable in practice.

Reeves et al1

There is nothing so practical as a good theory.

Lewin59

Theories enable educators to make visible existing problems and to ask new and important questions, both of which can inform everyday practice. In this light, the dichotomy between academic/theoretical knowledge and applied/practical work is artificial. Knowledge and practice are not separate. Indeed, practice is impossible without some kind of conceptual framework, and working with theory is as much about becoming aware of the assumptions that animate our choices and behaviors as it is about a deliberate search for new theories to apply. It is said that in psychotherapy, patients treated by therapists with a theoretical understanding of their problem have better recovery rates. Interestingly, it may be less important which theoretical model the therapist holds than that she or he does hold one.60 It seems probable that simply holding a theoretical framework is helpful for educators as well because having a theoretical framework allows for a reasoned choice of action that can be justified to oneself and discussed with others. Rees and Monrouxe61 quote Leonardo da Vinci as saying, “He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast.”

Just as medical educators encourage medical trainees to be reflective about their actions and the reasons for them, we encourage medical educators to be more reflective about the theories that guide their educational practices. A medical educator who feels strongly about a particular approach to learning and teaching (e.g., a pedagogical method, assessment framework, or model of student development) should think about what theoretical notions underlie his or her beliefs and behaviors, whether a particular theoretical framework could be used to better articulate those beliefs and behaviors, and to what degree others have examined the value of that particular theoretical perspective.

Sometimes, theoretical perspectives can be in tension.62 However, the goal of medical educators should not be to choose one best theory above all others. Our belief is that medical educators should avoid paradigm wars and disciplinary sniping. Successful examples of theoretical harmony already exist in the literature of medical education. For example, a recent national consensus process led by one of us (B.D.H.) identified, classified, and illustrated a range of theoretical perspectives on the much-debated construct of professionalism. The goal was not to reduce the multitude of perspectives on professionalism to a simple consensus but, rather, to illustrate the plurality of ways in which the construct can be understood, taught, assessed, and researched.63 Addressing professionalism at the individual level calls on theories related to personality or cognitive attributes. Social interactionist theories inform the structure of teaching and role modeling related to the interpersonal dimensions of professionalism. Finally, sociocultural theories can explain the political and economic drivers of institutional behavior and culture and how behaviors are shaped by hidden curricula. Kennedy and colleagues41 used a similar approach to compare and contrast what theories from counseling psychology, cognitive psychology, kinesiology, and sociology offer to improve our understanding of the phenomenon of progressive independence in clinical training.

Sociocultural theory is particularly applicable to graduate medical education because it is deeply embedded in workplace settings. In his book Profession of Medicine, Eliot Freidson64 argued decades ago that physician behavior is far more influenced by the nature of the workplace than by anything doctors learn as students. Recent calls for medical education reform, including the Carnegie Foundation's post-Flexnerian Educating Physicians: A Call for Reform of Medical School and Residency,65 the American Medical Association's Initiative to Transform Medical Education: Recommendations for Change in the System of Medical Education,66 and the Association of Faculties of Medicine of Canada's project The Future of Medical Education in Canada67 all demand greater attention to learning contexts, workplaces, and the roles of physicians in the societies to which they are accountable. Thus, while bioscience and learning theories will continue to be very important in medical education research and practice, underused sociocultural theories, with explanatory power at the level of the environments in which medicine is learned and practiced, may be particularly informative in responding to these calls for reform and redesign of postgraduate medical education.

To illustrate links between theory and practice, we created Table 2. There, we took three familiar graduate medical education objectives (learning technical/clinical skills; learning team collaboration; gaining progressive independence) and contrasted practices that are aligned or not aligned with the bioscience theories, learning theories, and sociocultural theories we presented in this article. For each, we have provided one or more references to publications cited in this article. These references were chosen not because they specifically address the practice elements included in the table but because they describe or use a theoretical perspective that would be consistent with engaging with or understanding each particular practice. Our goal in providing these elements is twofold: to illustrate the range of bioscience theories, learning theories, and sociocultural theories that can be brought to bear on practical problems, and to illustrate how authors have used theory to understand or evaluate similar, if not precisely the same, practices.

Table 2
Table 2
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How Does a Medical Educator Learn to Use Theories?

Medical education journals, once content to publish descriptions of innovative pedagogical methods or simple quantitative studies, are now turning to deeper theoretical questions including ontological and epistemological inquiries into the nature of health professional education.

Hodges62

Theories, by nature, are conceptual and explanatory and therefore built on layers and layers of scholarly work, research, writing, and debate. Theories are dynamic, evolving, and always at risk of being disproven. Engaging with theories, understanding their conceptual dimensions, and mastering the intellectual basis of their fundamental concepts are not easy tasks. Certainly, doctoral education requires engaging theories through in-depth study and is one way of learning to think, write, and work with theory. Medical education journals, conferences, and even day-to-day engagement with colleagues in medical education seem to demand an ever-increasing theory fluency. Graduate education is, of course, neither realistic nor necessary for all medical educators. Nevertheless, anyone setting out to master a theory-informed approach should understand that such mastery is going to take some work. Extensive reading is required. To use a theory in practice is to be able to articulate what one believes about education and the nature of the evidence that supports those contentions, as well as to recognize and embrace discussion and debate with others who hold different, but no less theoretically informed, points of view.

Bleakley and colleagues48 have argued that, whereas early 20th-century structural reforms in medical education revolved around a scientific imperative, today's reorientation of medical education around sociocultural axes requires the development of a corps of medical educators and clinical teachers with a strong grasp of theory, sustained by well-developed pedagogical and research skills. The source materials that medical educators of the future will need to read, they argue, are not simply those that describe methods for teaching, assessment, or research but, rather, those that help medical educators to deepen and transform their thinking in conceptual ways. The need for faculty development to support this process is evident.

We created this short review of the nature and use of theory in postgraduate medical education to make the topic more accessible, to illustrate the links between theory and practice in medical education, and to provide resources for further reading (see List 1). Mastering one or more theories is not a simple task, and medical education has lacked guideposts to help educators and administrators. We hope that this article goes some distance in showing the way forward.

List 1
List 1
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Acknowledgments:

The authors are grateful to Elisa Hollenberg for her assistance with the literature search and for editing this article.

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Funding/Support:

The authors received an honorarium for writing this article from the Josiah Macy Jr. Foundation, which commissioned it. One of the authors (B.D.H.) also received a travel allowance to attend and present an earlier version of this article at the Josiah Macy Jr. Foundation conference entitled “Reforming Graduate Medical Education to Meet the Needs of the Public” held in Atlanta, Georgia in May 2011.

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Other disclosures:

None.

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Ethical approval:

Not applicable.

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This article was commissioned for and presented at the Josiah Macy Jr. Foundation conference entitled “Reforming Graduate Medical Education to Meet the Needs of the Public” held in Atlanta, Georgia in May 2011.

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References

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