Journal Club: June 2013

By Jan D. Carline, PhD, director of Educational Evaluation and professor, Biomedical Informatics and Medical Education, University of Washington School of Medicine

Clinical Teaching Based on Principles of Cognitive Apprenticeship: Views of Experienced Clinical Teachers

Renée E. Stalmeijer, PhD, Diana H.J.M. Dolmans, PhD, Hetty A.M. Snellen-Balendong, MD, Marijke van Santen-Hoeufft, MD, Ineke H.A.P. Wolfhagen, PhD, and Albert J.J.A. Scherpbier, MD, PhD

About Cognitive Apprenticeship

Informal models of apprenticeship in clinical training have long been present in medical education. The more formal identification of its components and expert practices are more recent. The essay by Collins, Brown, and Newman in 1989 was a major step in applying cognitive science research to developing an ideal model of effective apprenticeship. Stalmeijer and colleagues have attempted to develop a similar model as applied to clinical medicine and through extensive interviews with clinicians to identify the appropriateness and usefulness of this model in understanding teaching in the clinical setting. The model has three major phases: initial modeling and establishment of a safe learning environment; coaching; and finally engaging the learner in self-directed learning.

Article Summary

In an iterative fashion, the authors worked with a group of experienced clinical teachers at Maastricht University to determine if the model of cognitive apprenticeship fits actual educational practice. Although all aspects of the model were recognized as important to teaching clinical skills, a number of factors played into how completely the model was fulfilled. Longer clerkships, more senior and motivated students, more experience in teaching, and a stronger interest in teaching all played into a more complete use of all facets of the model. The authors conclude that a longitudinal clerkship design coupled with a team approach to teaching and learning would improve clinical education.

Questions

  1. Does the apprenticeship model fit your own experience with effective clinical teaching?
  2. One finding was that skill and comfort in teaching came only with experience. What would be the preferred scheduling of attendings with students to ensure optimal teaching as well as skill development of the teachers?
  3. While motivation of students affected learning, interest of faculty in teaching was also related to success in employing the full apprenticeship model. Should interest in teaching be a requirement for placement of students with faculty?
  4. The authors suggest that students be prepared prior to clerkships to be assertive, effective communicators and to have personal educational objectives for clinical experiences to enhance their learning in the clinical setting? Is this a reasonable task? How might it be done before the student has any real knowledge of the clinical setting?

Further Reading

Collins A, Brown JD, Newman SE. Cognitive apprenticeship: Teaching the crafts of reading, writing, and mathematics. In: Resnick LB, ed. Knowing, Learning and Instruction: Essays in Honor of Robert Glaser. Hillsdale, NJ; Lawrence Erlbaum Associates, Inc.; 1989: 453-494.

Bleakley A. Broadening conceptions of learning in medical education: the message from teamworking. Med Educ. 2006;40:150-157.

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One Comment

  1. Kemi Tomobi
    June 27, 2013 at 3:48 AM

    It is quite interesting that the field of neuroscience, particularly cognitive science, is being used to fuel educational discussion and possible reform.  Upon discussion of cognitive apprenticeship, the first thing that comes to mind is the idea of immediate feedback in demonstrating cognitive gains in the clinical realm (G. M. El Saadawi et al., 2010).  Such an environment as we all know is not an exact replica of the real world, where we may not always have immediate feedback, but provides an initial safe, educational environment until one transitions to a point where there is more intuition, or “feeling of knowing.”  How long is that transition?  Can this be established on a short two week clinical experience or a much longer one?  Are the years of training reflective of the approach to feedback, where junior level students need more immediate feedback, and more senior level clinical students engage in more self directed learning? A 2012 study by D Murdoch-Eaton and J Sargent supports this idea.  Such a discussion on feedback affects the student-preceptor relationship.  I now attempt to answer the questions:

    1. Yes. A medical student’s goal is education first, and healthcare second.  In an ideal world, both would go together, and the medical student would know 110% of everything he or she needs for the first week of internship, but it is not always the case. The massive amount of cost of attendance to gain such a clinical experience should reiterate this fact. A resident or attending physician’s goal is healthcare first, and training medical students second.  These physicians are paid to do what they do, while medical students PAY to do what they do.  Therefore, conflicts may arise on busy services, or short-term services, where the medical student may not get the most out of his or her education.  Therefore, the smaller the ratio of students to faculty/residents, the more opportunity the student has to gain special experience.  The learning experience then becomes more effective, and may be useful in ultimately choosing a specialty, doing research with that mentor and getting published, or getting a letter of recommendation to apply for residency, awards, or other special program.  When I have one-on one experience with a clinical mentor, whether it is an attending or a very senior resident who has taken an interest in me, I learn much more, and am more confident in my skills.  The letters of recommendation are better, and the relationship is better.  Many who are in a position to design their own elective with a course director or other preceptor know what they want out of the experience and are able to guide their own learning.

    2.  That is a great question. The clinical years serve at least two purposes: to provide exposure to students so that they can choose a specialty, and, after committing to a specialty to expose students to electives and other experiences in medical school that they would not get in the committed residency of choice.  For example, someone rotates on dermatology and likes it, then commits to dermatology, may later decide to rotate on OB/GYN because they may want to learn about women’s health, or even about public health, or humanities, and may not get that useful learning after starting residency.

    Optimal scheduling for clinical rotation varies, except when applying to residency. For most residency programs, students have between July 1 and September 1 to rotate on specially-designed electives, get published, or pursue subinternships to get letters of recommendation, update the dean’s letter, and submit an early ERAS application. After the ERAS and dean’s letter are submitted, then students can pursue electives that would broaden their educational base, while interviewing and matching, and transitioning to life after medical school.

    3. Interest in teaching should be a requirement, but things like motivation and interest are so subjective and dynamic in different settings, that a perfect match of student and preceptor is more important than imposing the requirement of an interest in teaching.  Who knows, there may be a match for a student who is not interested in an attending who teaches.  Therefore,i would not make it a hard requirement.

    4.  Students should be assertive, but should gauge team dynamics.  There is a fine line between persistently “assertive”and annoying, and tired, overworked residents have a low threshold for annoyance.  What is also important is that extroversion is valued more than introversion (for now). Therefore, it is important to always be engaged and participate in rounds, asking and answering questions, and not being afraid to ask for help at the right time (remember that the priorities of students, residents, and attending physicians are different).

    Students may create educational objectives based on specialties of interest, performance on previous clerkships, or  . . . . mentoring.  Mentoring! Mentoring from peers who have recently done the rotation, or from faculty or other regular advisor who can offer insight into the rotation would be the best choices from which to draft educational objectives.

    References:

    Gilan M. El Saadawi, Roger Azevedo, Melissa Castine, Velma Payne, Olga Medvedeva, Eugene Tseytlin, Elizabeth Legowski, Drazen Jukic, and Rebecca S. Crowley.  “Factors affecting feeling-of-knowing in a medical intelligent tutoring system: the role of immediate feedback as a metacognitive scaffold.”  Adv in Health Sci Educ (2010) 15:9–30.

    Murdoch-Eaton, D, & Sargeant, J.  “Maturational differences in undergraduate medical students’ perceptions about feedback.” Medical Education 2012: 46: 711–721.

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