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The Practicality of Theory

Kuper, Ayelet MD, DPhil; Whitehead, Cynthia MD, PhD

doi: 10.1097/ACM.0b013e3182a66321

The study of medical education has broadened significantly over the past decade to include a wide variety of theoretical frameworks from multiple research domains. There remains a significant misconception, however, that learning theories (largely drawn from cognitive psychology and education) are practical and useful to educators, whereas other types of theory are not. The authors of this commentary reflect on a learning-theory-based model for developing master learners presented by Schumacher and colleagues in this issue of Academic Medicine. They suggest that bioscientific and sociocultural theories can enhance different aspects of that model and provide specific examples from neuropsychophysiology, Foucauldian discourse analysis, and critical theory. Bioscientific and sociocultural theories such as these present medical educators with an exciting array of new methodological and interpretive possibilities. The authors illustrate ways in which these theories can have important practical applications for, and impacts on, the practice of medical education.

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, Toronto, Ontario, Canada.

Dr. Whitehead is vice chair for education and associate professor, Department of Family and Community Medicine, University of Toronto, cross-appointed scientist, Wilson Centre for Research in Education, University Health Network/University of Toronto, and staff physician, Women’s College Hospital, Toronto, Ontario, Canada.

Funding/Support: The authors currently receive salary support from AMS Phoenix Fellowships (A.K. and C.W.) and a New Investigator Award from the Canadian Institutes of Health Research (A.K.).

Other disclosures: None.

Ethical approval: Not applicable.

Correspondence should be addressed to Dr. Kuper, c/o Wilson Centre, 200 Elizabeth St., 1ES-565, Toronto, Ontario, M5G 2C4, Canada; telephone: (416) 340-4194; e-mail:

Editor’s Note: This is a commentary on Schumacher DJ, Englander R, Carraccio C. Developing the master learner: Applying learning theory to the learner, the teacher, and the learning environment. Acad Med. 2013;88:1635–1645

The last decade has seen major changes in the field of medical education research. The paradigm wars between qualitative and quantitative methods have abated while the breadth of disciplinary perspec tives represented in our community has increased. Audiences at the worldwide medical education conferences we attend have seemed with each passing year less methodologically narrow and more open to new theoretical framings. Both at those conferences and in our reading of medical education journals, we see researchers using an ever-growing variety of theoretical approaches to answer old questions and to come up with new ones.

The authors of the article “Developing the master learner: Applying learning theory to the learner, the teacher, and the learning environment”1 published in this issue of Academic Medicine have intentionally limited their review of theoretical frameworks guiding the development of master learners to, specifically, learning theories. They write that, from within the gamut of learning theories, they have selected several on which to focus based on their “educational philosophies and experience as clinician educators,” specifying that they chose “theories derived from cognitive psychology, experiential learning, and social constructivism that have the most practical application and impact in the clinical learning environment.”1 These are reasonable choices—journal articles can be only so long, authors can be experts in only so much—and, of course, learning theories from these domains certainly have much to offer to the development of master learners.

There is, however, a prevailing mis conception in our field—to which Schumacher and colleagues, with their focus on application and impact, may have fallen prey—that, while learning theories can be practical, other kinds of theoretical frameworks are not. Medical education researchers have often rejected bioscientific theories as being too far removed from the clinical and educational realms, and they have often dismissed sociocultural theories as “wishy-washy” or impractical. Yet, as one of us argued recently in this journal,2 theories from these domains can be incredibly practical, providing significant insight into and impacting decisions ranging from medical student pedagogy to the design of health systems and institutions. How might these theories also apply to the development of the master learner?

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Insights from Neuropsychophysiology

One obvious example comes from recent work in the bioscientific, experimental field of neuropsycho physiology. As LeBlanc3 has highlighted, theory-based research examining the effects of physiological (e.g., cortisol measurements) and subjective stress on learning has shown it to affect attention and memory as well as decision making and team performance. She points out that studies of theoretical concepts, such as selective attention and memory consolidation, indicate that moderate stress can enhance learning, but only if stressors are integral to (and not distractions from) the task at hand. Neuropsychophysiology has also shed new light on the relevance of the traditional psychological notion of coping styles; for example, research shows that avoidant coping is associated with greater increases in cortisol levels.3 This research indicates that optimizing the master learner’s ability to learn should include teaching her to cope effectively with stress, and optimizing her context for learning should include encouraging moderate stresses that derive from the object of learning rather than from extraneous features in the environment.

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Using Foucault to “Make Strange”

While the preceding example offers an enhancement to Schumacher and colleagues’ model of the development of the master learner, other theoretical frameworks operate at different levels of analysis. Foucauldian discourse analysis,4 for example, is a sociocultural framework that allows us to question such models’ fundamental assumptions by exploring the relationship between language and the construction of social phenomena.5 Within this theoretical framing, the task shifts from answering a concrete question about the factors that contribute to the development of master learners to problematizing the socially constructed underpinnings of that very question. How, we might ask, have the social roles of learner and teacher been constructed in the first place? What are the effects of the commonplace positioning of learning as an individual skill in which a person gains mastery? What are the implications of the current shift away from educational processes to a focus on outcomes? How do we understand the particular focus on self-regulation at this historical moment? Asking and answering these questions does not belittle the original question being problematized but, rather, “makes strange”5 its taken-for-granted assumptions.

Such making strange may at first seem rather impractical, but it can have intensely practical effects. The basic tenets of our medical education system, like those of any institution, are not inevitable or “true” but, rather, the results of historically mediated, socially constructed happenstance. By making strange these supposed truths, theoretical frameworks like Foucault’s allow us to appreciate their constructed nature, identifying them as being the product of contingent social and historical forces. These previously unquestioned assumptions can then be examined, their positive and negative effects weighed, and deliberate decisions made about their appropriateness. For example, Hodges’ Foucauldian exploration of the discourses underpinning the shift from process-oriented, time-based medical education toward outcomes-oriented, competency-based medical education allows educators to move past divisions between the old “truth” and the new truth—that is, between the previous naturalness and seeming inevitability of time-based education and the currently assumed superiority of competency-based education—to make informed choices about the future of their training programs.6

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Power, Hierarchy, and the Learning Environment

Whereas many have used Foucault’s theories to argue for social change, some sociocultural theories are much more intentional and explicit in their focus on exposing inequities in order to improve both society and the plight of individuals who are disadvantaged within it. Examples of such theories, often referred to as “critical” theories, include neo-Marxist theories (which focus on income disparities and other forms of uneven distribution of wealth) and equity theories (e.g., feminist theories, antiracist theories, queer theories), both of which have been used in medical education research to study relationships within various learning environments. Baker and colleagues,7 for example, describe the implementation of an interprofessional education (IPE) program among health professionals and trainees at a group of hospitals affiliated with a large urban North American university. Using Witz’s8 feminist neo-Marxist “model of professional closure,” they explore the power struggles (which became evident through their interviews with both teachers and learners) that resulted in the IPE program reproducing, rather than breaking down, the traditional hierarchies that are detrimental to the functioning of interprofessional teams and to collaborative learning. This research7 indicates that optimizing the master learner’s context for learning must go well beyond providing safe spaces, up-to-date technology, and longitudinal interactions between teachers and students to also ensuring that the hierarchies and power struggles present in all learning environments are recognized and managed.

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An Exciting Array of Possibilities

There are many other sociocultural theories currently being used in medical education, each of which allows us to ask and answer different types of questions at different levels of analysis. Some focus on macro issues such as exposing and disrupting the production and reproduction of inequities by the medical education system; others focus on micro issues such as exploring and improving aspects of individual physician–patient interactions. These theories draw from many different disciplines and fields in the social sciences and humanities: sociology, anthropology, political science, literature, cultural studies, rhetoric, history, linguistics, and many others. Each opens up new ways of seeing the world and, in turn, new questions to ask, new assumptions to unearth, and new possibilities for change.

Despite their exciting potential for underpinning change in medical education, we recognize that not everybody in the medical education community is going to individually engage with bioscientific and sociocultural theories. Nonetheless, we are confident that our field as a whole will continue to apply these theories, recognizing the many useful insights and innovations with which they have already provided us. Over the past 10 years, we have shaken off the vestiges of the previous era, wherein the only legitimate discipline within medical education research was cognitive psychology, and we have made room for a rich array of new theoretical possibilities. Now is the time to realize just how practical all those theories can be.

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1. Schumacher DJ, Englander R, Carraccio C. Developing the master learner: Applying learning theory to the learner, the teacher, and the learning environment. Acad Med. 2013;88:1635–1645
2. Hodges BD, Kuper A. Theory and practice in the design and conduct of graduate medical education. Acad Med. 2012;87:25–33
3. LeBlanc VR. The effects of acute stress on performance: Implications for health professions education. Acad Med. 2009;84(10 suppl):S25–S33
4. Foucault M The Archaeology of Knowledge. 1972 London, UK Routledge
5. Kuper A, Whitehead C, Hodges BD. Looking back to move forward: Using history, discourse and text in medical education research: AMEE guide no. 73. Med Teach. 2013;35:e849–e860
6. Hodges BD. A tea-steeping or i-Doc model for medical education? Acad Med. 2010;85(9 suppl):S34–S44
7. Baker L, Egan-Lee E, Martimianakis MA, Reeves S. Relationships of power: Implications for interprofessional education. J Interprof Care. 2011;25:98–104
8. Witz A Professions and Patriarchy. 1992 London, UK Routledge
© 2013 by the Association of American Medical Colleges