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Education Theory Made Practical: Volume 4


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This is the fourth volume of the popular series: Education Theory Made Practical which has been brought to you as a joint effort between the Academic Life in Emergency Medicine (ALiEM) Faculty Incubator program and the International Clinician Educator Blog. This project is made possible in part with funding from the Government of Ontario and through eCampusOntario's support of the Virtual Learning Strategy. To learn more about the Virtual Learning Strategy visit:
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Krzyzaniak | Messman | Robinson | Schnapp | Li-Sauerwine | Gottlieb | Chan
Education Theory Made Practical: Volume 4
Published by McMaster Office of Continuing Professional
Development, Hamilton, ON, Canada.
Supported by Academic Life in Emergency Medicine,
San Francisco, California, USA.
First edition, February 2022
This project is made possible in part with funding by the
Government of Ontario and through eCampusOntario’s support of
the Virtual Learning Strategy. To learn more about the Virtual
Learning Strategy visit:!
Available for usage under the Creative Commons Attribution-
NonCommercial-NoDerivs 3.0 Unported!License.
ISBN: 978-1-927565-46-9
A Project of the Faculty Incubator
Academic Life in Emergency Medicine
Sara M. Krzyzaniak, MD
Anne Messman, MD
Daniel Robinson, MD, MHPE
Benjamin Schnapp, MD, MEd
Simao Li-Sauerwine, MD, MSCR
Michael Gottlieb, MD
Teresa Chan, MD, MHPE
constructed from data without any presupposed starting position. In this way,
medical education can use multiple theories to help make sense of the issues
confronting learners, teachers and educators.2 But, unlike the clinical domain
clinician-educators simultaneously reside in, there is no hierarchy of better/best
theories in medical education. There is no one theory to rule them all. The issues
in medical education are too nuanced and complex for such a rigid approach.
Here lies the value of ETMP. While I have specific theories (looking at you Cog-
nitive Load Theory) that I draw on more regularly, I appreciate a vast number of
theories relevant to my work in medical education. While I have grown as a clin-
ician-educator since my first grad school course, there is still much for me to dis-
cover and learn. ETMP introduces to me, in an applied manner, theories that can
bring fresh insight or better explanation to the questions I face in my education
practice. Krzyzaniak, Messman, Robinson, Schnapp, Li-Sauerwine, Gottlieb, and
Chan have edited a concise, well-referenced, practical, and highly readable re-
source for clinician-educators, regardless of level of experience. I look forward to
discovering Joplin’s model of experiential learning, while contrasting it with the
chapter on Kolb’s experiential learning. Scanning the table of contents reveals
chapters relevant to teaching, learning, assessment, wellness, and more.
I wish I had ETMP when I started grad school. I prescribe it to my grad students
and medical education fellows now. Volume Four is an excellent addition to the
cannon of ETMP.
Jonathan Sherbino, MD, MEd
Professor of Medicine
Assistant Dean of Health Professions Education Research
McMaster University
1. van Enk, A., & Regehr, G. (2018). HPE as a field: implications for the pro-
duction of compelling knowledge.!Teaching and learning in medicine,!30(3),
2. Varpio, L., Paradis, E., Uijtdehaage, S., & Young, M. (2020). The distinctions
between theory, theoretical framework, and conceptual framework.!Acade-
mic Medicine,!95(7), 989-994.
Chapter 1!!!!!!Cognitive load theory
!!!!!!!!!!!!!!!!!!!!!!! Sonia Twigg, MBBS; Andrew Little, DO; Moises Gallegos, MD
!!!!!!!!!!!!!!!!!!!!!!! Editor: Sara M. Krzyzaniak, MD
Chapter 2!!!!!!Epstein’s mindful practitioner
!!!!!!!!!!!!!!!!!!!!!!! Krystin Miller, MD; Kelsey Vargas, MD, Guy Carmelli, MD
!!!!!!!!!!!!!!!!!!!!!!! Editor: Simiao Li-Sauerwine, MD, MSCR
Chapter 3!!!!!! Joplin’s five-stage model of experiential learning
!!!!!!!!!!!!!!!!!!!!!!! Mark Keuchel, DO; Alai Alvarez, MD; Curtis Knight, MD
!!!!!!!!!!!!!!!!!!!!!!! Editor: Teresa Chan, MD, MHPE
Chapter 4!!!!!!Kolb’s experiential learning
!!!!!!!!!!!!!!!!!!!!!!! Brian Barbas, MD; Anita Thomas, MD, MPH; Derek Monette, MD, MHPE
!!!!!!!!!!!!!!!!!!!!!!! Editor: Benjamin Schnapp, MD, MEd
Chapter 5!!!!!! Maslow’s hierarchy of needs
!!!!!!!!!!!!!!!!!!!!!!! Greg Kelly, MBBS; Laryssa Patti, MD
!!!!!!!!!!!!!!!!!!!!!!! Editor: Michael Gottlieb, MD
Chapter 6!!!!!!Millers pyramid of assessing clinical competence
!!!!!!!!!!!!!!!!!!!!!!! Eric Blazar, MD; Vimal Krishnan, MD; Shivani Mody, DO
!!!!!!!!!!!!!!!!!!!!!!! Editor: Dan Robinson, MD, MHPE
Chapter 7!!!!!!Multiple resource theory
!!!!!!!!!!!!!!!!!!!!!!! Matt Zuckerman, MD; Alison Hayward, MD, MPH
!!!!!!!!!!!!!!!!!!!!!!! Editor: Benjamin Schnapp, MD, MEd
Chapter 8!!!!!!Prototype theory
!!!!!!!!!!!!!!!!!!!!!!! Meenal Sharkey, MD; Mary Bing, MD, MPH; Kimberly Schertzer, MD
!!!!!!!!!!!!!!!!!!!!!!! Editor: Anne Messman, MD, MHPE
Chapter 9!!!!!!Self-Regulated learning
!!!!!!!!!!!!!!!!!!!!!!! Annahieta Kalantari, DO; Eric Lee, MD; David Zodda, MD
!!!!!!!!!!!!!!!!!!!!!!! Editor: Simiao Li-Sauerwine, MD, MSCR
Chapter 10!!!!Siu and Reiters TAU approach
!!!!!!!!!!!!!!!!!!!!!!! Sugeet Jagpal, MD; Leon Melnitsky, DO;! Samuel Zidovetski, MD, MPH
!!!!!!!!!!!!!!!!!!!!!!! Editor: Anne Messman, MD, MHPE
Education Theory Made Practical (Volume 4) is the fourth volume in a well-
established series of eBooks that aims to connect theory to clinical education.
It continues our case-based discussion of core theories and frameworks in
medical education. A collaborative project between the Academic Life in
Emergency Medicine ( and the International Clinical Educator
(ICE blog), this project has helped many clinician educators to gain a better
sense of how education theories and frameworks can apply to their daily
Each chapter was written and edited by clinician educators for clinician edu-
cators and then released on the ICE blog over a six month period. The posts
are open for peer review by our health professions education community
broadly and then edited by our editors into this final compendium.
As with our previous books, each chapter begins with a common case that
educators may face in the clinical or classroom setting followed by a discus-
sion of the featured theory itself, its modern applications, and finally the case
is closed by articulating how the theory could augment education practice.
Additionally, we include an annotated bibliography so that readers can easi-
ly find additional resources for further learning. Each chapter can be read
independently or as an entire book at the reader’s preference.
This book (and its source materials) were originally derived as a part of the
Free Open Access Medical Education (FOAM or #FOAMed) movement and
funded by the Government of Ontario’s eCampus Ontario initiative. We are
thankful for the funding from our sponsoring agency to assist with being
able to make this resource open access to the world.
The Education Theories Made Practical eBook series was designed to pro-
vide an efficient primer on ten core educational frameworks or theories that
can be applied by the reader in a practical manner, while also providing a re-
source for identifying further relevant literature.
This work has been funded by a generous grant from eCampus Ontario, which is an
initiative of the Government of Ontario (Canada).
Available for usage under the Creative Commons Attribution-NonCommercial-
NoDerivs 3.0 Unported!License.
Where can I find this online?
This book can be found in the ALiEM Library (, Apple Bookstore,
ResearchGate, and the Government of Ontario’s eCampus library.
Sara M. Krzyzaniak, MD
Anne Messman, MD
Daniel Robinson, MD, MHPE
Benjamin Schnapp, MD, MEd
Simao Li-Sauerwine, MD, MSCR
Michael Gottlieb, MD
Teresa Chan, MD, MHPE
Jonathan Sherbino
A Case
It’s a nightshift in your busy ED. The ED is pumping and Sarah, a senior resident, is running the pod. She
has seen sick patient after sick patient and knows there are still long waits for patients in the waiting room.
She is going as fast as she can and juggling as many patients as possible.
She is seeing Mr. Smith, her fifth patient with chest pain this shift. Mr Smith is in his 60s and has a typical
presentation for ischemic chest pain: heavy central chest pressure for the past 30 minutes. He is
hemodynamically stable and his pain improves after aspirin and sublingual nitro. His ECG shows ST
depressions in V1-V3. Sarah makes sure she follows the department’s chest pain protocol including orders
for serial troponins and ECGs, as well as sublingual nitro as needed. She expects Mr Smith has had a
Another critical patient arrives, so she drops what she is doing to go and care for that patient. 30 minutes
later she is called to Mr. Smith’s bedside by his nurse who is concerned that he is looking worse. Mr. Smith
is diaphoretic, tachycardic, and has become hypotensive. Reviewing the initial ECG, her attending points
out that the ST depressions in the anterior leads are concerning for a posterior STEMI. The attending
orders a posterior lead ECG which demonstrates ST elevations in V7-V9, confirming her suspicion.
Sarah is upset about this missed diagnosis and the delay in care that it created. She wonders if she would
have been able to arrive at the correct diagnosis if she had not been distracted by her other patients and
frequent interruptions.
Authors: Sonia Twigg, Andy Little, Moises Gallegos
Editor: Sara Krzyzaniak, MD
Cognitive Load Theory
John Sweller
Other important authors or works:
Van Merrienboer JJ and Sweller J. Cognitive load theory in health professions education:
design principles and strategies. Med Educ (2010) 44: 85-93.
Sewell JL, Maggio L, ten Cate O et al. Cognitive Load theory for training health
professionals in the workplace: A BEME review of studies among diverse profession:
BEME guide No. 53. Medical Teacher (2019) 41(3): 256-270.
Young JQ, Van Merrienboer J, Durning S et al. Cognitive load theory: implications for
medical education: AMEE Guide No. 86. Medical Teacher (2014) 36: 371-384.
In a series of papers during the 1980s, Sweller1 began to outline his observations that a high
cognitive load negatively impacts learning.
“Cognitive load” is composed of intrinsic load, extraneous load, and germane load.
Intrinsic load refers to the demand created by the complexity of the task itself, taking into
account the performer’s experience.
Extraneous load refers to demand created by stimuli that are present but not related to the
task itself, i.e. distractions.
Germane load refers to the demand that results from efforts to link working-memory with
long-term memory.
Germane load can be thought of as the process of learning. If the intrinsic and extraneous load
are too great, we become cognitively overloaded and have little to no capacity for germane load
- we can’t learn!
Cognitive Load Theory (CLT) suggests we should design education and performance systems
match intrinsic load to the knowledge and experience of the learner. (We don’t want our
novice learners overwhelmed, and we don’t want our advanced learners bored.)
minimise extraneous load.
optimise germane load.
Cognitive Load Theory builds on Atkinson and Shiffrin’s model for human memory.3
Sensory inputs enter into our working memory, and we organize (“chunk”) this information
into “schemas” that are then stored in long term memory. Working memory is limited. At any
given time we can hold 7+/- 2 items in our working memory for only 30 seconds. Long term
memory is infinite, but we have to retrieve the schemas back into working memory when we
need them. Working memory becomes the bottleneck for learning. Over time, and with
repeated experiences, specific schemas become more complex, organized and eventually
automated -- this is expertise.4 A single schema, however complex, counts as one item in
working memory. The premise of CLT is that the processes of learning may be different from
the processes required to complete a task. If working memory is spent on tasks that do not
contribute to the development of schemas from working memory to long-term memory,
learning cannot occur.
Intrinsic load describes the cognitive demand of the task itself.2 Intrinsic load is affected by
task complexity and the prior knowledge of the learner. Complex tasks, with a high number
of elements or highly interactive elements, impose a higher intrinsic load than simple tasks.3
Let’s use the example of analyzing an ECG. Rare or subtle ECG findings are harder to pick up
than obvious ones. Novice learners experience a higher intrinsic load than experienced
learners doing the same task. An experienced senior resident would be expected to analyze
the same ECG faster and more accurately than a medical student.
Extraneous load is the extra information we experience that is not necessary to complete the
task yet uses up part of our precious working memory.2 It’s what gets in the way of doing the
task: the buzzer that goes off while you are reading the ECG, the interruption with a
question, the poor print out, and the time pressure of the busy ED. Each of these work to
increase your cognitive load and make reading the ECG harder. But it’s not always bad!
Sometimes the extra information helps you elaborate the schema. For example a quick review
of STEMI mimics from an online reference before reading the ECG may help you make the
correct interpretation of the ECG.
Germane load describes the effort associated with learning. It is the load we experience from
processing the information in our working memory into (or out of) the schemas we store in
long term memory.3 It is closely linked with intrinsic load, but it relates more to the attention
devoted to learning rather than the effort dedicated to actually performing the task (i.e.
intrinsic load).
Modern Takes on this Theory
In 2010 Van Merrienboer and Sweller offered principles to guide instructional design in
medical education.4 Fraser et al.!elaborate on them in their 2015 review of how CLT applies to
healthcare simulation.5
Strategies to manage intrinsic load:
Sequencing effect: present simple concepts first followed by more complex ones.
Segmenting effect: divide a task into manageable “chunks” and once schemas have been
formed for each, combine them to perform the whole task (i.e. create one schema).
Pre-training effect: teach components of a task before the whole task. For example in a
healthcare simulation, do a pre-brief on how the mannequin and simulation monitors
Low to High Fidelity effect: start with a low fidelity environment and build up.
Strategies to decrease extraneous load:
Goal free effect: specify tasks without a single answer, e.g. rather than asking “What is this
patient’s diagnosis?” one should ask “List as many differential diagnoses you can for this
Worked example effect: Demonstrate to the learner how to perform a task.
Completion effect: offer partially completed tasks, e.g. “Please finish this management
Split attention effect: don’t split the learner’s attention, e.g. don’t use a slide graphic whose
key is on another slide or on a handout
Modality effect: use both visual and auditory modes when presenting information.
Redundancy effect: don’t give redundant info. Replace multiple sources with a single
source of information.
Strategies to optimize germane load:
Variability in practice effect: offer tasks that provide variation on a theme, e.g. read many
different types of STEMI ECGs.
Contextual interference effect: give a series of tasks that use different skills (high contextual
Self-explanation effect: prompt the learner to “self-explain”, e.g. “Write down why you came
to this diagnosis.”
Cognitive load & instructional design:
Leppink describes three dimensions that help guide instructional design6:
1. Task fidelity
2. Task complexity
3. Instructional support
He recommends that fidelity and complexity should be gradually increased while ensuring
adequate instructional support, and then ultimately fade the instructional support when it is no
longer needed.
These principles help explain the “expertise-reversal effect”. As the learner becomes more
advanced, techniques that previously augmented learning for the novice actually start to
interfere. For example, asking an expert to use an unfamiliar mnemonic for a task they already do
well provides too much instructional support which increases extraneous load.
A fundamental characteristic of health professions is the collaborative nature of care. Research
has begun to explore the application of CLT to group-based learning and teamwork. Kirschner et
al have promoted the “interaction hypothesis” to explain the differences in learning efficiency for
groups and individuals.7,8!They discuss the impact of utilizing a combined, or collective,
working-memory, in the development of schema. In a group setting, cognitive load can be
distributed to the working memory of various team members for processing. Large quantities of
information are serially distilled into workable inputs that team members can then use to form
schema. This can be useful when dealing with high complexity tasks that would otherwise
overload an individual. However, with low complexity tasks, distribution of cognitive load may
leave individuals without enough effortful processing of information to allow for appropriate
schema development. It becomes “a trade-off between the group’s advantage of dividing
information processing amongst the collective working memories of the group members and its
disadvantage in terms of associated costs of information communication and action
Fraser et al have begun to look at how emotion affects cognitive load.5!They point out that the
activation of emotion is inevitable in healthcare simulation, among other situations in medicine.
Emotion can increase extraneous load, but it is sometimes an important component of intrinsic
load, e.g. when learning to break bad news. Positive emotions appear to improve learning,
perhaps through improving motivation and attention or through improving problem solving and
creativity. Stress appears to have varying effects; it can focus attention and improve schema
formation for the task at hand, but it also decreases working memory and can impair retrieval
from long term memory. Healthcare teams have been shown to increase performance when
feeling psychologically safe, so if psychological safety is present, “academic emotions,” such
as performance anxiety and motivation to learn, can be optimized.
Other Examples of Where this Theory Might Apply
The argument can be made that the Flipped Classroom model for teaching benefits from
application of CLT!by creating protected learning time through removing it both temporally
and spatially from preparatory time.9 The inherent separation of preparatory work from active
application creates a focus on germane load during in-person sessions and off-loads intrinsic
and extraneous processes. The design principles proposed by Van Merrienboer and Sweller!to
improve the balance of cognitive load in health professions education can be applied to
optimize the preparatory material and in-person sessions that create a flipped learning
Simulation-based learning forms an important tenet of skill development and critical action
decision making. However the complexity of cases and skills taught through simulation may
result in too high a cognitive load. CLT can be applied to simulation curricula for improved
results.5!While running a simulated pediatric resuscitation, a trainee may become
overwhelmed trying to remember medication dosages and lose track of the experiential goals
for the session. Providing a Broselow tape, or better yet a confederate such as a pharmacist,
would allow the learner to focus on building skills as a team leader.
CLT has been applied to performance in medicine as well as learning. Sewell!examined
cognitive load as it applies to performing a colonoscopy.10 The same group has also looked at
how cognitive load impacts patient handovers.
Limitations of this Theory
De Jong criticized CLT by pointing out that while it describes a cognitive basis for
instructional design principles, it is “impossible to falsify” because CLT relies on post-hoc
assumptions.12!If the load imposed by the task interferes with our schema construction, we
think it’s bad and label it as extraneous load. If it helps us construct schema, then we think it’s
good and label it as germane load. In other words, we make the evidence fit the theory.
Perhaps we could justify this labeling if we could directly or accurately measure cognitive
load. Current measures include:
Psychometric testing. Paas developed and validated a single-item scale, which is the most
commonly used measure.13!In contrast the NASA-Task Load Index (NASA-TLX) is a multi-
item scale.14!Unfortunately these are self reported measures that occur after the task has
finished. They may not reflect the load during the task, and they only measure overall
cognitive load.
Secondary task response. The speed and accuracy of performing a secondary task, for
example giving a medication order while reading the ECG. While you are concentrating on
that complex ECG, you might start mumbling or pausing while giving the medication order.
Physiologic measures. Heart rate or respiratory rate variability, EEG or EMG monitoring, eye
tracking, pupillary diameter, blink frequency, serum adrenaline levels, brain imaging and
skin conductance have all been examined and validated. Their supposed advantage is that
they can measure cognitive load instantaneously and continuously over time.
Performance on the task.3!Examining how well is the task performed, e.g. number of errors
made during task, can provide insight into how much cognitive load was involved in the
It is arguable whether these are valid or accurate measures. What are they really measuring?
While they are general measures of cognitive load, most do not measure its constituent parts
of intrinsic, extraneous and germane load. In other words, they can tell us that cognitive load
affects performance but not how the different parts interact.
In 2013, Leppink developed a psychometric instrument to differentiate between different
types of cognitive load.15!However in a subsequent review, it was noted that some studies did
not support the instrument described.6!The authors of the review suggested that we go back
to a two factor framework and think of cognitive load as consisting of only intrinsic and
extraneous load along with a “subjective judgement of learning.” Young and Sewell disagree
and have derived instruments to measure the different types of load in medical settings
including colonoscopy10!and patient handovers.16 In 2016, Naismith developed the Cognitive
Load Component (CLC) psychometric test and compared it with the Paas and NASA TLX
tests.17!This interesting but small study showed little agreement on total cognitive load
between the three tests. However intrinsic load seemed consistently measured by all three.
Intrinsic load on the CLC correlated with the NASA TLX subscales of mental demand and
CLT makes intuitive sense, but we have more research to do to demonstrate how it applies to
instructional design and workplace performance.
Returning to the case...
After her whirlwind shift, Sarah is finally able to catch her breath and reflect on Mr. Smith’s
case. Luckily he was taken to the cath lab 20 minutes after discovering the posterior MI where
emergent PCI and stenting of a 90% occluded RCA occurred without complications and he was
transferred to the CCU in stable condition.
She recognizes that as a senior resident she should be more capable of identifying this common
ECG pattern. She plans to spend some time on her day off studying ECGs (decrease intrinsic
load) and will set a systematic approach for when she is handed ECGs on shift making sure she
pauses for each (decrease extraneous load).
Van Merrienboer JJ and Sweller J. Cognitive load theory in health professions education:
design principles and strategies. Med Educ. 2010;44: 85-93.
This paper gives the clearest advice on pragmatic strategies for incorporating CLT into the
design of medical education curriculum of all types.
Young JQ, Van Merrienboer J, Durning S et al. Cognitive load theory: implications for
medical education: AMEE Guide No. 86. Medical Teacher. 2014;36:371-384.
This guide clearly describes CLT in terms of its origins in models of human memory, its
relation to other learning theories, and how expertise is developed.
Sewell JL, Maggio L, ten Cate O et al. Cognitive load theory for training health
professionals in the workplace: A BEME review of studies among diverse profession:
BEME guide No. 53. Medical Teacher. 2019;41(3):256-270.
Sewell et al provide a scoping review of CLT literature. Specifically they discuss practice
points for workplace teaching, curricular design, learning environment, and metacognition.
They conclude that CLT alone cannot account for the complex environment created by health
profession education workplaces and would benefit from integration with other education
theories and frameworks.
Kirschner PA, Sweller J, Kirschner F, Zambrano R J. From cognitive load theory to
collaborative cognitive load theory. Int J Comp Supported Collab Learn. 2018;13(2):213-233.
This paper provides a review of the principles in human cognitive architecture that first led
to CLT, how CLT can be applied to instructional design, and how CLT can be combined with
the cognitive interdependence principle to create Collaborative Cognitive Load Theory.
1. Sweller J. Cognitive load during problem solving: Effects on learning. Cognitive Science.
2. Sewell JL, Maggio L, ten Cate O et al. Cognitive load theory for training health
professionals in the workplace: A BEME review of studies among diverse profession:
BEME guide No. 53. Medical Teacher. 2019;41(3):256-270.
3. Young JQ, Van Merrienboer J, Durning S et al. Cognitive load theory: implications for
medical education: AMEE Guide No. 86. Medical Teacher. 2014;36:371-384.
4. Van Merrienboer JJ and Sweller J. Cognitive load theory in health professions education:
Design principles and strategies. Med Educ. 2010;44:85-93.
5. Fraser KL, Ayres P, Sweller J. Cognitive load theory for the design of medical simulations.
Sim in Healthcare. 2015;10(5):295-307.
6. Leppink J and Van den Heuvel A. The evolution of cognitive load theory and its
application to medical education. Perspect Med Educ. 2015;4:119-127.
7. Kirschner F, Paas F, Kirschner PA. Individual and group-based learning from complex
cognitive tasks: effects on retention and transfer efficiency. Computer Hum Behav.
8. Kirschner F, Paas F, Kirschner PA. Task complexity as a driver for collaborative learning
efficiency: The collective working-memory effect. Appl Cogn Psych. 2011;25: 615-624.
9. Abeysekera L and Dawson P. Motivation and cognitive load in the flipped classroom:
Definition, rationale and a call for research. Higher Ed Res and Dev. 2015;34(1):1-14.
10. Sewell JL, Bocardin CK, Young JQ. Measuring cognitive load during procedures skill
training with colonoscopy as an exemplar. Med Educ. 2016;50:682-692.
11. Kirschner, PA, Sweller J, Kirschner F, Zambrano R J. From cognitive load theory to
collaborative cognitive load theory. Int J Comp Supported Collab Learn. 2018;13(2):213-233.
12. De Jong T. Cognitive load theory, educational research, and instructional design: Some
food for thought. Instr Sci. 2010;38:105-134.
13. Paas F. Training strategies for attaining transfer of problem-solving skill in statistics: A
cognitive-load approach. Journal of Educational Psychology. 1992;84:429-434.
14. Hart SG, Staveland LE. Development of NASA-TLX (Task Load Index): Results of
empirical and theoretical research. Advances in Psychology.!1998;52:139-183.
15. Leppink J, Paas F, Van der Vleuten C et al. Development of an instrument for measuring
different types of cognitive load. Behav Res. 2013;45:1058-1072.
16. Young JQ and Sewell JL. Applying cognitive load theory to medical education: Construct and
measurement challenges. Perspect Med Educ. 2015;4:107-109.
17. Naismith LM, Cheung JJH, Ringsted C, Cavalcanti R. Limitations of subjective cognitive load
measures in simulation based procedural training. Med Educ. 2015;49:805-814.
A Case
John, a senior resident in emergency medicine, just opened the chart of Mr. Smith on a busy Monday after-
noon shift. He thought the name sounded familiar, and in fact he had seen the patient before. The patient
has visited the emergency department several times for chronic back pain, most recently one week ago. Prior
clinicians have documented concern for drug-seeking behavior. Begrudgingly, John prepares to go see the
patient. Today, the patient’s chief complaint is back pain and leg pain.
John takes a very abbreviated history from the patient. John feels like this is a difficult patient encounter, as
the patient is grumpy and uncooperative and is asking repeatedly for pain meds. Mr. Smith answers simple
yes or no questions but fails to provide additional details. However, John doesn’t push back with any follow-
up questions. At the same time as he is interviewing Mr. Smith, John is filling out his chart and also inter-
rupting the patient several times to ask a nearby nurse about his other patients.
John determines Mr. Smith is having low back pain that is radiating to his feet. The patient was witnessed
during examination to have an antalgic gait. Mr. Smith has no “red flag symptoms” including trauma,
malignancy, incontinence to bowel or bladder or new neurologic deficits. The patient was examined fully
dressed, but John feels he has obtained an adequate exam for the complaint. John determines there is no in-
dication for further testing or imaging at this time. John communicates with the attending that the pa-
tient’s pain is likely an exacerbation of his underlying degenerative disc disease and sciatica. He would like
to offer the patient acetaminophen for pain and discharge to home without further diagnostics.
Prior to the attending seeing the patient, the patient’s nurse approaches the team and states, “I’ve taken
care of Mr. Smith before, and he just doesn’t seem himself. His vitals today are abnormal. He has a slight
fever with tachycardia and his blood pressure is lower than he usually runs. I am concerned we might be
missing something here.”
The attending sends John back to the bedside to re-evaluate the patient.
Authors: Krystin Miller, MD; Kelsey Vargas, MD; Guy Carmelli, MD
Editor: Simiao Li-Sauerwine, MD, MSCR
Epstein’s Mindful Practitioner
Ronald M Epstein
Other important authors or works:
Suzuki S. Zen mind, beginner's mind: Informal talks on Zen meditation and practice.
Shambhala Publications; 2010.
Streng FJ. Emptiness: A study in religious meaning. Abingdon Press; 1968.
Mindfulness is a derivation of Zen Buddhist meditation. The general teaching is on being fo-
cused on the present and maintaining moment by moment awareness.1 Mindfulness has since
transitioned into the medical field, beginning in medical school curricula, encouraging budding
students to listen more attentively to their patients, become more aware of their own mental
processes, and recognize their own biases and judgements.2 Mindfulness practices have been
shown to better allow physicians to care for the patients through compassion and understand-
In Emergency Medicine (EM), qualities deemed important to being a good EM physician in-
clude compartmentalizing, multi-tasking, and pattern recognition. However, while these traits
generally allow EM physicians to more efficiently triage critical versus non-critical patients,
these qualities may interfere with the holistic approach to treating the patient. The constant in-
terruptions, patient overcrowding, inpatient boarding, and hospital oversight and policies all
contribute to disengagement and reflexive thinking in many physicians’ decision-making pro-
In contrast, mindfulness is a state of welcoming uncertainty in place of avoidance which frees
up the physician from being limited by factors out of their control. Mindful practice opens up
the physician to be aware of the complexity of the situation and his or her inherent biases in or-
der to stop, think, and configure a treatment plan that encompasses what is best for the patient.
Ronald Epstein is the founder of mindfulness in medicine. Ronald Epstein matured in an age
of counterculture and the partnered threats of conflict in the mid-20th century. This era of
turmoil led to a life-long practice that has become integral in his daily practice.4 Epstein’s fa-
ther served as an army physician and Epstein himself went through the motions of what was
expected: attending university with the expectations of becoming a doctor. However, while he
was finishing up college, he felt that something was missing. Early 20th-century medicine had
evolved into viewing the human body as a machine, and the mechanics (i.e. doctors) fixed
machines. This practice was at odds with how Epstein viewed the overall goals of medicine.
In 1971, he took a course in Transcendental meditation and this gave him a glimmer of light.
He eventually left school and moved to the West Coast where his journey through meditation
His route back to medicine was to discover research on the medical benefits of meditation,
eventually choosing Harvard Medical School, a powerhouse of innovative research. His re-
search unearthed studies suggesting that blood pressure, chronic pain, anxiety, and other
medical conditions could benefit from meditation. He graduated medical school and became a
family medicine practitioner who incorporates traditional holistic teachings into patient care.
He turned meditation into mindfulness in practice-- incorporating the fundamentals of medi-
tation into clinical shifts and the struggles that physicians face day-to-day.2
The foundation of Zen Buddhism cultivates present moment-to-moment awareness and
awareness of self. It begins with a quiet setting, relaxing in a comfortable position, and focus-
ing on breathing. When the mind starts to wander, it purposefully brings itself back to the fo-
cus on each individual breath. Each wander becomes shorter until the mind is clear enough to
be in the present moment alone. Mindfulness is attending to the ordinary, the obvious, and
the present.2 To see the ordinary in a day full of critically ill patients is to see the family mem-
ber that continues to ask for updates because they are scared and confused and to understand
that your frustration is not with this family member, but with the workload, the lack of re-
sources, and the inability to save each patient.
A second purpose of Zen is awareness of self— to understand one’s own thoughts, feelings,
and flaws.4 Zen is the ability to allow the emergence of feelings without attempting to change
or judge them, permitting these feelings to “just be.” However, a second foundation is living
selflessly, understanding that there are times when a feeling does require change. One of Ep-
stein’s stated goals was to “have more intentional unselfish awareness moments than selfish
ones.” It is considered a universal human capacity to foster clear thinking and open-hearted-
Applying this process to patient care requires the provider to actively observe the patient,
themselves, and themselves with the patient. Physicians are human, therefore one should at-
tempt to understand inherent biases that are brought to a patient encounter in order to em-
pathize and connect with the patient for improved care.
Modern Takes on this Theory
Historically a Buddhist practice, mindfulness itself requires no religious or cultural affiliation,
and rather can be used in any setting as our innate ability to foster clear thinking and open
heartedness.1 The underlying philosophy of mindfulness is based on the interdependence of
action, cognition, memory and emotion.1 Being that medicine is an intersection between art
and science, mindfulness practices made an easy transition into the field of medicine.
The current era of medicine is filled with constant distractions, whether by email, cell phones,
or other technological devices. The new age of medicine comes with increased demands to
improve productivity often at the expense of the patient-physician relationship. Many physi-
cians state that they lack sufficient time with patients to explore the depth of their experiences
and how it relates to their medical presentation.3 Rather, pressure from administration and the
medical system leads many practitioners to rely on instincts and first impressions to make
quick decisions.
Mindfulness, a practice of nonjudgmental moment-to-moment awareness, is one way for
physicians to become aware of these patterns of behavior, habits, and reactions.3 Patient-cen-
tered care emphasizes understanding the patient as a person and encouraging a more partici-
patory patient-physician relationship.5 This type of relationship has the appearance of in-
creased time requirements in a world where practitioners are suffering through multi-tasking
and quick paces. However, one can make a meaningful connection by sitting down, engaging
with the patient, and not rushing through depersonalized conversations. One uninterrupted
encounter with the patient answering questions and explaining diagnoses and plans generally
takes less time that multiple short, interrupted interactions where neither the patient nor the
practitioner feel satisfied with the outcome.
Modern medicine makes room for different applications of mindfulness to suit the individ-
ual’s needs. Practitioners may keep a journal, meditate, or even review recordings of patient
encounters.2 In medical education, learner self-evaluation forms are a great way for the stu-
dent or resident to reflect on their experience and compare perceptions with their teachers
and/or mentors.2 Furthermore, peer evaluations and critical incident reports can bring
awareness to aspects of professionalism, difficult situations, gaps in medical knowledge and
social skills for students, residents, and practicing physicians.2
Studies have been published showing the many positive benefits of practicing mindfulness.
One publication showed that introducing a mindfulness-based stress reduction educational in-
tervention to medical students led to a decrease in total mood disturbance.6 Another study
showed that mindfulness training in students can reduce psychological distress and feelings of
burnout, improve well-being and mood, and increase patient empathy.7,8 Finally, a qualitative
study of primary physicians who received a mindfulness communication program showed that
the physicians consequently felt a reduction in professional isolation, improvement in atten-
tiveness, and an increase self awareness.9
Other Examples of Where this Theory Might Apply
Habits of mind, including use of attentiveness, curiosity, flexibility and presence, are important
features for patient care and physician well being. Epstein discussed his 8-fold approach for
teaching mindful practice in medicine:10
1) Priming- Setting the expectation of student self-observation.
2) Availability- Creating a quiet, uninterrupted space to interact.
3) Asking reflective questions- Questions designed to foster curiosity.
4) Active engagement- Being physically and mentally present with the student.
5) Modeling- Showing actions while “thinking aloud” to make the tacit explicit.
6) Practice- Disciplined repetition in controlled settings.
7) Praxis- Motivating students to put knowledge into practice.
8) Assessment and confirmation- Evaluate mindfulness and presence.
Evidence-based decision models are benefited by mindful practice-- applying data from groups
of patients to the care of one patient.5 However, this practice is limited by incomplete tacit pa-
tient information.2 Mindfulness can bridge the gap between evidence-based and relationship-
centered care, overcoming the limitations of both approaches. Mindfulness helps a provider
formulate a clinical question, find appropriate sources and then bring the information back to
the bedside.
There are many examples of mindfulness practices in the hospital. One example is the “sterile
cockpit rule.”11 In air travel, this rule prohibits any flight crew member from engaging in any
non-flight related activity or conversation during a critical phase of flight. Similarly, this can be
used in the operating room, during resuscitations, or prior to procedures. This mindfulness
practice of being in the moment and free from distractions is an excellent clinical tool and appli-
cation of the theory.
Returning to the Case
On re-evaluation, John confirms the patient is indeed febrile, tachycardic and now hypotensive. John de-
cides to take a much more detailed history and perform a more thorough examination of Mr. Smith after he
is completely changed into a hospital gown. John discovers that the patient has been sleeping in a homeless
camp for the past month and has been out of his diabetes and hypertension medications for approximately 6
months. Over the last 3-4 weeks, the patient has developed wounds on both of his feet, which he was initial-
ly embarrassed to tell anyone about. He has been feeling progressively worse, with fever and chills for about
one week now. Ultimately, the patient gets admitted to the hospital for sepsis and requires podiatric inter-
John and the attending debrief about the patient encounter, and the attending asks John some reflective
“What assumptions did you make when you first opened the chart?”
“What did you miss in that first interview with the patient?”
Epstein RM. Mindful practice in action (II): Cultivating habits of mind. Families Systtems &
Health. 2003;21:11-17.
This second article in a two-part series outlines Epstein’s eight-fold method for promoting
mindfulness in medical education. The eight areas include; priming, availability, asking reflec-
tive questions, active engagement, modeling while thinking out loud, practice, praxis, and as-
sessment and confirmation. For each of these areas, the article provides practical application of
the theory to medical education.
Epstein RM. Just being. West J Med. 2001;174:63-65.
This article by Epstein, discusses the importance of self care, meditation, and mindfulness. It
concludes with providing resources that offer instruction on the topic area, as well as strategies
for health professionals to enhance their well-being.
Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300:1350-1352.
This JAMA commentary, published in 2008, provides a concise overview of the applications of
Epstein’s theory of mindfulness in medicine. In this article, the authors consider mechanisms of
mindfulness as well as clinical applications, and also discuss some limitations of the current re-
search in the field.
John reflects on the assumptions he made about the patient and his personal biases that he brought to the
encounter - multiple ED visits, chronic pain, non-specific complaints, prior clinicians report of drug seek-
ing behavior. He also stated that he rushed through the interview and wasn’t attentive to the patient’s non-
verbal cues during the interview. While the patient was a difficult historian, John reflects that he did not
ask appropriate prompting questions to build rapport and gain the patient’s trust.
“What changed the second time you went into the room, John?”
John mentioned that he was more actively engaged and brought a new mindset to the encounter. He started
from square one, with a blank slate, ignoring previous documentation that could lead to the formation of bi-
ases. During the second encounter, John also worked to leave his personal judgements and opinions at the
door, and be more present and in the moment during the interaction.
John and the attending concluded with a discussion on mindful practice with an emphasis on being aware
of our own judgements and categorizations during clinical encounters. Mindful practitioners are able to
put these aside to demonstrate compassion, treat the patient as a whole person, and be attentive to the pa-
tient’s needs.
1. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300:1350-1352.
2. Epstein RM. Mindful practice. JAMA. 1999;282:833-839.
3. Connelly JE. Narrative possibilities: Using mindfulness in clinical practice. Johns Hopkins
University Press. 2005;48:84-94.
4. Epstein RM. Just being. West J Med. 2001;174:63-65.
5. Epstein RM. Mindful practice in action (I): Technical competence, evidence-based medicine,
and relationship-centered care. Families Systems & Health. 2003;21(1): 1-9.
6. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress re-
duction lowers psychological distress in medical students. Teach Learn Med. 2003;15(2):88–92
7. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on med-
ical and premedical students. J Behav Med. 1998;21(6):581-599.
8. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mind-
ful communication with burnout, empathy, and attitudes among primary care physicians.
JAMA. 2009;302:1284–93.
9. Beckman BH, Wendland SM, Mooney EC, Krasner LM, Quill MT, Suchman MA, et al. The
impact of a program in mindful communication on primary care physicians. Acad. Med.
10.Epstein RM. Mindful practice in action (II): Cultivating habits of mind. Families Syststems &
Health. 2003;21:11-17.
11.Ornato JP, Peberdy MA. Applying lessons from commercial aviation safety and operations
to resuscitation. Resuscitation. 2014;85:173–176.
A Case
The interns had an upcoming simulation module on placing central lines. A small group of them decided to
show up early to play around with the equipment and see if they can practice on their own. Each of them
had either seen one performed or got to place one during medical school. Everyone had an idea of what the
correct steps were and each one felt comfortable practicing without the assistance of an instructor giving
them direct feedback.
John, one of the interns, grabbed the syringe and attempted to cannulate the internal jugular in the man-
nequin. He kept poking the neck and was getting frustrated. Jill, recalling some steps from when she did
placed a line, took over. She started telling John her version of how it should be done. Jim read out loud the
steps emailed for their asynchronous learning as Jill continued to attempt with the cannulation. Everyone
was feeling frustrated without the teacher.
Authors: Mark Keuchel, D.O.,Al’ai Alvarez, M.D.,Curtis Knight, M.D.
Editor: Teresa Chan, MD, MHPE
Joplin’s Five Stage Model of Experiential Learning
Dr. Laura Joplin’s theory suggests that all learning is experiential. According to Joplin’s theory,
a person learns from “experiencing” and interacting with the subject. Dr. Joplin felt that experi-
ential learning programs had two main responsibilities to the learner:
1) Provide an experience
2) Provide a reflection period on that experience.
These two phases of learning are joined in the “action-reflection” cycle. According to Joplin, the
simple provision of an experience by itself is not sufficient for learning; a learner’s reflection on
the action is of critical importance.
The five-stage model describes an experiential learning strategy that combines the following
stages: 1) Focus; 2) Action; 3) Support; 4) Feedback; 5) Debrief.
Feedback and support are critical throughout the process from the moment of initial action
through the conclusion of the learning experience. This framework gives educators a model to
deliberately strengthen the experiential nature of their course design, highlighting that it is the
educator’s responsibility to provide a learner-centered education.
Joplin’s five-stage model was created to be intentionally simple and define the act of learning, but
is not a learning theory itself. The model is organized around a ‘hurricane-like cycle’ in which a
challenging action occurs between the initial focus stage and the final debriefing. These ‘action-
reflection’ cycles are differentiated from experience alone by incorporating a reflection process.
The application of the cycles can be in either a ‘maxi’ or ‘mini’ scope, depending on the intent of
the project; the cycle can focus on large-scale course design or a brief teaching moment or insight.
The first aspect of the model is the focus stage. It is here that the educator identifies the task and
the attention of the learner becomes engaged. The educator is tasked to shine light on a specific
topic to help orient the learner. The education must also be cautious not to be too specific, as this
cause learners to have tunnel-vision. The focus stage is necessary to align the learner’s attention
with the educator’s goals. Actions in the focus stage depend on the type of activity to be per-
formed. A focus stage may be as simple as verbally discussing the goals or it may be more com-
plex, such as reviewing an article before an action.
The second part of the model is the action stage. This stage of the model surrounds the learner in
direct confrontation with an often-unfamiliar situation requiring the learner to engage in problem
solving. The inherent stress of the situation gives the learner an “experiential” learning. Active
learning is facilitated by participation rather than passively reading or watching a video. The
learner must be given “responsibility” in the learning process, a component that is absent in text-
books where the author decides the sources. The education is responsible for ensuring the learn-
ing difficulty is appropriate for the learner. By actively engaging the learner, the brain is consid-
ered “on” and the new information can be processed and retained.
Modern takes on this theory
The intentional aspect of Joplin’s five-stage model of experiential learning requires time and work
that may not always be feasible in the clinical setting. Moreover, there is a generational difference
in perception of teaching and learning. Because Joplin’s model can be applied in a “maxi” and
“mini” scope, it is easily translatable in a busy shift. Knowing the five stages is important, and de-
liberate signposting of these steps may help learners better appreciate the process. Here’s how:
Laura Joplin
1. “Let’s focus your attention to the way you’re holding the syringe.” [focus]
2. “I’m going to give you feedback on what I’m seeing you do and how it may affect the suc-
cess of your venous cannulation.” [reflection: feedback]
3. “I’m going to give you a more specific feedback. I’m noticing your angle is too steep. How
can you optimize this to allow the wire to thread easily?” [specific feedback, challenging]
4. “I like how you’re stabilizing your hand as you advance the guidewire through the needle.
It helps prevent kinking of the wire.” [specific support]
5. “That’s great. You’ve advanced the wire successfully, and I’m noticing that you’re holding
the wire carefully so as not to lose it. How do you want to proceed?” [debrief]
In a “maxi” application of Joplin’s model, consider the process of training as a team for a Sim-
Wars competition. A group of residents are selected to represent the department. Each one has a
specific skill set needed for success, yet team cohesion is a very important characteristic of a win-
ning team. A deliberate focus on developing this sense of teaming is a must. As the team practices
different approaches to crisis resource management, the team must reflect on the efficiency and
effectiveness of their communication styles. This aspect of teaming must be intentionally and
consistently supported. The feedback must also be specific regarding the delegation of roles, the
use of closed-loop communication, and the appropriate tone and delivery of orders. For every it-
eration, each of these areas must be addressed for improvement, including highlighting success-
fully performed tasks. Ultimately, the five stages are repeated using multiple sources of feedback;
support and challenging occur as the team advances. Once ready, the team will demonstrate a
well-rehearsed, cohesive implementation of crisis management. A final debrief is critical in order
to further emphasize areas for improvement and celebrate successes.
Other Examples of Where this Theory Might Apply
Another example for the use of Joplin’s five stages is the framework for a residents-as-teachers
model. By clearly defining the steps in successful learner-centered teaching, a junior teacher (res-
idents) are able to be deliberate in their approach to teaching. Not only will they gain experience
in mastery of the topics they are teaching, they will also apply the metacognition of effective
teaching styles.
Limitations of this Theory
Joplin’s five-stage model is clear, deliberate and learner-centered - but teacher intensive. The time
requirement and effort required for preparing adequate experiences and creating the feedback
and debriefing to match the initial experience is not to be taken lightly. In order to be effective,
Joplin’s five-stage model requires time and intentionality. On shift teaching using Joplin’s model
may not be feasible as we often cannot put a patient through several iterations of a procedure.
From a learner’s perspective, learning in this model can be exhausting, thereby defeating the
point of a learner-centered teaching. It is important to cultivate buy-in from the learner and
acknowledge early on that rapid cycles of observation and feedback may lead to feedback
fatigue. Frequent check-ins are important, and the teacher must create a supportive learning
climate for the learner to work independently with fewer intrusions.
Returning to the case...
The group of interns realized that experience alone is not effective to learn how to place central venous
catheters. They needed an instructor to tell them what they were doing right and what they were doing
wrong. When the teacher arrived, she used Joplin’s five-stage model to provide a deliberate method for
reflection at each step of the cycle. This encouraged them to develop mastery at each step of the process. The
key is not to simply be lucky with cannulating the vein. An experienced teacher can help guide the process
and solidify technical skills for each step. The teacher offered individualized support for each learner. She
gave specific feedback in the moment along with appropriate corrective actions. The teacher provided
support for successful completion of each task. At the end of the workshop, each of the learner felt confident
about their skills and was able to demonstrate mastery of the procedure. A debriefing session followed to
discuss scenarios and offer troubleshooting tips. Simulation workshops are a great way to teach procedural
skills, especially using Joplin’s five-stage model of experiential learning.
Joplin L. On Defining Experiential Education. Journal of Experiential Education.
This paper introduces the idea of the 5-stage model of experiential learning. Her model is orga-
nized around a “hurricane-like cycle” emphasizing a challenging action that occurs between an
initial stage of focus and a final debriefing stage. Feedback and support are present throughout
all stages.
Kolb DA. Experiential learning: Experience as the source of learning and development. Upper
Saddle River, NJ: Prentice Hall; 1984.
This book by Kolb built upon earlier work and lead him to believe that knowledge acquisition
was obtained through “transformation of experience.” His theory had 4 stages in a cyclical pat-
tern: concrete experience, reflective observation, abstract conceptualization, and active experi-
mentation. This is an interesting theory that overlaps and augments the work of Joplin and is
worth comparing and contrasting.
1. Andreasen RJ and Wu C. Study abroad program as an experiential, capstone course: A pro-
posed model. Journal of International Agricultural and Extension Education. 1999;6(2): 69-78.
2. Joplin L. On defining experiential education. Journal of Experiential Education. 1981;4(1):17-20.
3. Kolb DA. Experiential learning: Experience as the source of learning and development. Upper Sad-
dle River, NJ: Prentice Hall; 1984.
4. Torock JL. Experiential learning and cooperative extension: Partners in non-formal educa-
tion for a century and beyond. Journal of Extension [On-line]. 2009;47(6) Available at: https://
A Case
It is a busy Sunday evening in your emergency department. Jared, a fourth year medical student, is com-
pleting his case presentation to Dr. Jones: “…so, in assessment, Sarah is a 2-year-old female with a 2 cm
linear forehead laceration, that I think requires suture repair.”
“Sounds good,” Dr. Jones replies. Since she has never worked with Jared before, she asks, “Do you feel com-
fortable suturing?”
“Definitely, I’ve sutured a bunch on other rotations,” Jared replies.
Dr. Jones nods. She has two other learners to check in on and patients are piling up in the waiting room.
She decides to trust Jared’s self assessment. “Okay, I’ll order the topical anesthetic, intranasal midazolam,
and have the nurse administer the midazolam about 5 minutes before we go in.”
Dr. Jones then sees several other patients and realizes that it has been about 45 minutes since topical anes-
thetic was applied to Sarah’s laceration. She walks into the patient’s room just as the nurse is administering
intranasal midazolam and Jared is setting up the laceration tray. After restraining Sarah and attempting to
distract her with her parents’ phones, it becomes apparent that Sarah was not sedated sufficiently, resulting
in her screaming throughout the procedure. Her parents are very distressed, intermittently in tears and an-
gry with the whole healthcare team.
“He told us that she would be completely asleep!” Sarah’s parents exclaim, pointing at Jared.
Dr. Jones attempts to de-escalate the situation by highlighting the amnestic effects of midazolam and re-
marks that Sarah likely does not like being restrained. She reiterates that this is a common anxiolytic in this
age group for this procedure and that she does not typically recommend full sedation for this type of proce-
While Dr. Jones is talking to Sarah’s parents, Jared starts to irrigate Sarah’s laceration, causing Sarah to
cry even louder. At this point, Dr. Jones says, “I think it might be better if I did the repair.”
Authors: Anita Thomas, MD, MPH, Brian Barbas, MD
Editor: Benjamin Schnapp, MD, MEd
Kolb’s Experiential Learning Theory
Jared is confused, but he pushes the laceration tray towards Dr. Jones. He watches the rest of the procedure
silently, annoyed and feeling out of place.
After the laceration repair, Dr. Jones rushes out of the room to see another patient. Jared lingers with Sarah
and her parents, discussing post laceration repair care. After several minutes, he steps out of the room to
grab a popsicle for Sarah. He plans to discuss what happened, but by the time he had a moment to grab Dr.
Jones, she had left for the day. Both of them were left wondering how the situation could have gone better.
David Kolb
As the name suggests, Kolb’s theory of experiential learning posits that much of learning takes
place as we make sense of the experiences that we have. The four steps of Kolb’s theory are:
concrete experience, reflective observation, abstract conceptualization, and active experimenta-
tion. Learning processes that are directly across from each other on the learning cycle (Figure 1)
are related. Concrete experience and abstract conceptualization can be viewed as grasping ex-
periences whereas reflective observation and active experimentation as transforming experi-
Figure 1: A graphical depiction of Kolb’s learning cycle, with the arrows indicating the tradi-
tional order of each step.2
While first published in 1984 by educational theorist David A. Kolb, the influences behind expe-
riential learning theory (ELT) can be found in the works of many before him including John
Dewey, Kurt Lewin, Jean Piaget, and many more.
The concept of experiential learning can be seen as far back as the teachings of Confucious
around 450 BC: "Tell me, and I will forget. Show me, and I may remember. Involve me, and I
will understand.”3 In the early 20th century, this concept took hold in modern educational theo-
ry. During this time period, psychologist John Dewey posited that “there is an intimate and
necessary relation between the process of actual experience and education.”4
During the 1940s, while studying group dynamics, social psychologist Kurt Lewin and his col-
leagues made note of the experiential learning process at work. While exploring the conversa-
tion about “the differences of interpretation and observation of the events by those who partici-
pated in them,” Lewin observed that learning is best facilitated in a setting in which there is an
active balance between immediate concrete experiences of learners and the detached analytic
feedback of the group.1 This lead to the creation of the National Training Laboratory in Group
Development, which inspired the learning cycle at the base of Kolb’s ELT.1
Meanwhile, Piaget’s work exploring the cognitive-development process in childhood led to the
development of another learning theory. Through his studies, Piaget argued that “intelligence
arises as a product of the interactions between the person and his or her environment.”1 In oth-
er words, as Kolb summarized Piaget’s work, “intelligence is shaped by experience.”1
Modern takes on this Theory
Experiential learning is essential to all of medical education. Nearly all of residency is an
experiential learning process involving concrete experience, reflective observation, abstract
conceptualization, and active experimentation under supervision. Kolb’s theory is so ingrained
within medical education that most literature on practical application of Kolb’s ELT is related to
clinical applications. Every patient interaction, new procedure, and bedside teaching moment
with a medical student is an opportunity to witness Kolb’s ELT in action. Multiple times in a
shift, a residents has a concrete experience, reflects on the experience, thinks of a plan to
improve, and applies the changes on the next similar experience. In studies of resident
education, Kolb’s ELT serves as at least a partial explanation for what is retained, highlighting
the importance of trainees’ patient encounters.5,6
Other Examples of Where this Theory Might Apply
Clinically: Kolb’s theory of experiential learning can be applied to almost any patient encounter,
but clinicians (including medical students, residents, and fellows) must actively engage in the
steps. Reflection may be more likely after recognized medical errors, but the goal is for it to occur
after almost every patient encounter. For example, a trainee might attempt to reduce a pediatric
nursemaid’s elbow, which was actually been a supracondylar fracture. Discovering this on x-ray
may lead to reflection and abstract conceptualization of why this patient had a fracture rather
than a nursemaid’s elbow. Active experimentation would occur as they create their treatment
plan for their next pediatric patient with elbow pain.
Classroom: Kolb’s theory applies well to the simulation environment. Simulated patient scenar-
ios provide a concrete experience. Debriefing encompasses reflective observation and abstract
conceptualization. Debriefings often start with open-ended questions such as “How did that
feel?” allowing for the group to begin the process of reflective observation while discussing the
most salient points of the case. Reviewing and reflecting on that shared experience ideally results
in abstract conceptualization. For instance, a facilitator may start a discussion with, “Tell me
about how you were thinking about whether to give fluids for this patient,” which can lead to a
shared mental model of why fluids were desired and in what quantity. Active experimentation, or
trying out variations on what was learned, can then be accomplished in subsequent simulations
and in real patient encounters. Simulation can allow for all four steps of Kolb’s theory in quick
succession by stopping participants when an error is made, offering immediate time for reflection
and learning (which is not generally present in the real clinical environment), and repeating the
simulation from the beginning so that active experimentation with new knowledge can be put
into practice right away, a technique called rapid cycle debrief practice.9
Additionally, Kolb’s theory can be applied to morbidity and mortality (M&M) conferences, which
start with a concrete clinical experience that has an unanticipated outcome, then allows for reflec-
tive observation and abstract conceptualization about more ideal management with the group.
For example, if a patient with a headache after a concussion was ultimately diagnosed with a
brain tumor after several clinical visits, the case serves as a surrogate concrete clinical experience
for the primary clinician. Specifics of each visit, including the history, exam, and decision making,
are generally reviewed during the conference, thus creating a shared mental model for all atten-
dees. Generally, groups then reflect on each visit and discuss the clinical scenario. Often, other
clinicians will utilize abstract conceptualization with comments like "Well, if I had been the pri-
mary doctor, then I may have ordered head imagine because of multiple visits,” or “I probably
would have treated the patient similarly because of lack of concerning symptoms." The purpose
of M&M conferences is to reflect and increase awareness of such cases, such that attendees keep
them in mind and potentially change their behavior when seeing similar patients in the future -- a
perfect example of active experimentation.
Kolb can be utilized as a framework for workshops as well. Structuring workshops with breakout
sessions allows participants to reflect on their concrete experience. It also provides time to apply
concepts learned during the workshop and conceptualize ways to change/improve their practice.
Depending on the workshop topic, a workshop may allow for active experimentation as well. For
example, in a quality improvement workshop, participate could be asked to reflect on quality is-
sues the have experienced (concrete experience), think about how they have been addressed (re-
flective observation), consider what makes for a successful quality improvement project (abstract
conceptualization), and brainstorm an opportunity for improvement in their own clinical envi-
ronment (active experimentation).
Limitations of this Theory
It can be difficult to accomplish all of Kolb’s stages in a real clinical environment as it requires de-
liberate reflection and repeated experiences. In an emergent situation, like performing CPR on a
dying patient, there might not be time to guide a learner through reflection, conceptualization,
and experimentation. Additionally, the goal for a learner would be for the Kolb cycle to be self-
sustaining, but the cycle does require some level of intrinsic motivation unless there is an external
facilitator. For a trainee who is burned out, Kolb’s theory may not be relevant as the learner may
not have the capacity to tackle a multi-stage learning cycle.
Additionally, while Kolb’s learning cycle shows a continuous progression, in reality, different
stages might occur out of order or simultaneously, which can be difficult to predict. It may be use-
ful to lay out Kolb’s learning theory when engaging with a trainee to employ a shared mental
model for learning, such as how to approach a new procedure.
Lastly, Kolb’s ELT does not consider the social context of the learning, including power dynamics
between teachers and learners.11 If a medical student is fearful of being reprimanded in front of
the entire team, they may be less open to sharing experiences or open reflection. Additionally, it
does not take into account racial- or gender-based dynamics. A female intern of color might have
a different concrete experience than a white male intern. Effects of prior learning experiences are
called out in Kolb’s ELT, but they play a large role in shaping learning for a trainee. For example,
a learner who has already seen many patients with chest pain during their rotation will have dif-
ferent experiences and reflections than a learner who has seen relatively few patients with chest
Returning to the case...
A few days later, Jared returns for another shift and eagerly picks up another facial laceration case, this time
with a 3-year-old patient.
“Hi Dr. Jones, I have a 3-year-old male with a 2 cm forehead laceration that needs repair. I’ve already dis-
cussed intranasal midazolam use with the family and the nurse applied the topic anesthetic. I feel comfort-
able repairing with your supervision.”
Dr. Jones nods and gestures towards Jared to sit. “I’ve been thinking about the laceration we had together a
few days ago.” She wanted to use this clear concrete experience as a discussion point with Jared. Aiming to
open the door for reflective observation, she asks Jared: “How did that feel to you?”
Kolb DA. Experiential learning: Experience as the source of learning and development. 2nd
Edition. Upper Saddle River, NJ: Pearson Education, Inc; 2015.
The first edition (1984) of this book introduced Kolb’s experiential learning theory. This updated
edition still contains the original underlying structure behind the theory, while also discussing
research supporting the theory over the past 30+ years, addressing concerns with the original
publication and displaying current examples of experiential learning both in the field and in the
Kolb DA, Boyatzis RE, Mainemelis C . Experiential learning theory: Previous research and
new directions. In R. J. Sternberg & L.-f. Zhang (Eds.), Perspectives on thinking, learning, and
cognitive styles. Lawrence Erlbaum Associates Publishers; 2001:227-247.
This chapter reviews the basics of ELT and how different learning styles fit into them. Learning
styles address how learners reconcile conflicts within learning processes, and include accom-
modating, diverging, assimilating, and converging.2
Yardley S, Teunissen PW, Dornan T. Experiential learning: AMEE guide No. 63. Medical
Teacher. 2012;34:102-115.
This paper reviews theories behind experiential learning as it relates to medical education, in-
cluding the background of experiential learning. Importantly, this paper discusses other theories
that have added to Kolb’s ELT and points out that in medical teaching, implementation of
Kolb’s theory often goes without support at each stage, which can be detrimental to the learner.
Support for both learners’ conditions and processes for experiential learning can lead to im-
proved outcomes of the learning.11
“It was really stressful for me because I felt like I didn’t get a chance to try,” Jared replies.
Dr. Jones asks, “What could I have done to help you?”
“Well, I would have liked to have at least tried more than irrigating. But, I don’t think I prepared the fam-
ily well enough for the sedation. I thought we would knock the kid out! I think I started out on the wrong
foot with the family and it seemed like you took over because they were upset.”
Dr. Jones notes that this is a powerful reflective observation. Dr. Jones stands up and motions for Jared to
walk with her to the procedural practice area. “I think one part of the issue is that I did not assess your
familiarity with the types of sedation we use for pediatric procedures. What I discussed with the family
when they were upset is typically how I prepare them for intranasal midazolam use.” (Dr. Jones reflec-
tively observes and initiates abstract conceptualization)
“Yeah, it was useful to be there for that discussion and I used it to model how I spoke to the patient’s fami-
ly today.” Dr. Jones nods, noting that today’s patient is a concrete experience where Jared can engage in
active experimentation.
“That’s good to hear,” Dr. Jones replies. “Let’s walk through your approach in a pediatric patient. We can
practice the procedure on this practice suture pad. We can discuss how I prepare families for the repair
and when it would be appropriate for me to intervene.”
As they walk through laceration repair, Dr. Jones spends five minutes reviewing her laceration repair
checklist with Jared in an effort to engage in abstract conceptualization.
“I hope that was helpful,” Dr. Jones says as they walk back over to the work area.
“To be honest, at first I didn’t think I actually needed to review laceration repair, but I see how it can be
different in a pediatric patient. I do feel more prepared and am excited to do this one, but understand
clearly when you would need to intervene.” Jared replies. Dr. Jones notes again that Jared is engaging in
more reflective observation.
“Okay, gather your supplies, and come grab me when the nurse has given intranasal midazolam and we
can do this laceration together,” Dr. Jones states to Jared. She hopes that prepping Jared will not only set
him up for success, but also make for a better experience for the patient and family. They are both, in a
way, engaging in active experimentation - Jared in his laceration care, and herself in terms of her supervi-
sion of trainees.
1. Kolb DA. Experiential learning: Experience as the source of learning and development. Prentice-
Hall; 1984.
2. Kolb DA, Boyatzis RE, Mainemelis C . Experiential learning theory: Previous research and
new directions. In R. J. Sternberg & L.-f. Zhang (Eds.), Perspectives on thinking, learning,
and cognitive styles. Lawrence Erlbaum Associates Publishers; 2004:227-247.
3. Pickles T, Greenaway R. Experiential learning articles + critiques of David Kolb's theory. website.
ing.htm#ixzz5ws8QAc1s. Accessed 17 Aug. 2019.
4. Dewey J. Experience and Education. Simon and Schuster; 1938.
5. White JA, Anderson P. Learning by internal medicine residents: Differences and similarities
of perceptions by residents and faculty. J Gen Intern Med. 1995;10(3):126-132.
6. Chung PJ, Chung J, Shah MN, Meltzer DO. How do residents learn? The development of
practice styles in a residency program. Ambul Pediatr. 2003;3(4):166-172.
7. Ha CM, Verishagen N. Applying Kolb’s learning theory to library instruction: An observa-
tional study. Evid Based Libr Inf Pract. 2015;10(4):186.
8. Healey M, Jenkins A. Kolb’s experiential learning theory and its application in geography in
higher education. J Geog. 2000;99(5):185-195.
9. Lemke D, Fielder EK, Hsu DC, Doughty CB. Improved team performance during pediatric
resuscitations after rapid cycle deliberate practice compared with traditional debriefing: A
pilot study. Pediatric Emergency Care. 2019,35(7):480-486.
10. Kolb DA. Experiential learning: Experience as the source of learning and development. 2nd
Edition. Pearson Education, Inc; 2015.
11.Yardley S, Teunissen PW, Dornan T. Experiential learning: AMEE guide No. 63. Medical
Teacher. 2012;34:102-115.
A Case
Since moving to the city one year prior, Ahmed had developed an outstanding reputation with his medical
team. He was older than most of the other fellows, having started surgical training in Syria before making
the switch to emergency medicine in the U.S.. Unsurprisingly, his technical skills were excellent, but it was
his calmness, humility, and patience that made him so popular with the department. “We love Ahmed” had
become a refrain amongst the nurses when they saw his name on the roster after what had been a few legen-
darily hectic night shifts, even for this hospital. The delicious food that his wife sometimes brought in for
everyone only further boosted his reputation.
Ahmed had moved with his family from a smaller regional hospital after failing his first attempt at the
board exams. His mentor there, a friend of the medical director, had personally called to recommend him.
“Ahmed’s fantastic, he’s not someone we’re trying to get rid of at all. But as you know, the teaching culture
here is not what it could be, and you’ve built a great reputation at your shop. Ahmed is clinically excellent
and works really well with our team, but he came from a very different system and English is not his first
language. I don’t have any doubts that he can pass, but I don’t know if he will from here. I think exposure to
your teaching program is what he needs to get him through.”
The boards were a month away and there were a record four fellows sitting. After participating in the local
study group for almost a year, Ahmed had become much more comfortable with case discussions in English.
He’d been meeting regularly with local mentors to talk over recent articles and had facilitated a great dis-
cussion at the local trauma study day, where he demonstrated his deep experience of gunshot wounds. Re-
cently though, this had all been starting to slip. His grand rounds presentation was, frankly, embarrassing
and required his co-presenter to step in and save the day. He’d been rude to a surgical attending who he’d
called overnight and several nurses had complained about his recent behavior. Kerry, the medical director,
didn’t believe in letting things fester. She saw him walk past her open office door and leapt up from her
desk. “Ahmed, do you have a few minutes to talk?” He’d been to her office a few times since he arrived. She
loved the way he prepared and drank tea in such a fastidious but elegant way. They’d covered all topics
from medicine to Ahmed’s hopes for his homeland and his family. He was someone who she and most of the
faculty saw as a potential future colleague who would bring great strength and diversity to the departmen-
t.This time, as he closed the door and turned back to face her, Kerry saw a completely different expression
from Ahmed’s usual one. Worry, fear, even anger flashed across his drawn face. She asked Ahmed to sit
down and said “Do you want some tea?” What was going on?
Authors: Laryssa Patti, MD and Greg Kelly, MBBS
Editor: Michael Gottlieb, MD
Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs is a comprehensive theory of human motivation. It attempts to
explain all aspects of human motivation by encompassing the full range of needs from those
necessary for survival to the need for self-actualization and spirituality. These needs are orga-
nized in a hierarchy of “pre-potency”, meaning that basic needs must be met prior to higher
level needs being addressed. The lower level needs (in ascending order) include physiological
requirements, safety, love, and esteem. The highest levels of the hierarchy include self-actualiza-
tion, realizing one’s unique potential. In Maslow’s later work, this included transcendence, go-
ing beyond one’s self.
Examples of the lower level needs:
Basic Physiological Needs: Things vital to survival (e.g., air, food, water, warmth, sleep).
Safety Needs: Things that give people control over their lives (e.g., shelter, financial security,
personal health and wellness).
Love Needs: Social interactions (e.g., friendships, family relationships, romantic partners, in-
teractions with community groups).
Esteem Needs: Interactions that give a sense of appreciation and respect, both from an indi-
vidual’s community as well as their own self-esteem and sense of accomplishment.
If all of these needs are met, the individual can pursue self-actualization, which Maslow defines
as “the individual doing what he [or she] is fitted for.”1
Abraham Maslow
Other important authors or works:
Fredrick Herzberg
Carl Rogers
In 1943, Abraham Maslow published “A Theory of Human Motivation”,1 in which he described
the concept of a hierarchy of needs that motivate human behavior. Maslow’s work arose from the
humanistic school of psychology, standing in contrast to the behavioralist school. With reference
to education, the behaviorist view was that education was a science that involved transmitting
knowledge in the most efficient way. In contrast, the humanists took a more holistic view of peo-
ple and believed that that an educator's role was to facilitate the growth of their students, en-
abling them to self-actualize.2
Maslow posited a hierarchical relationship between physiological needs and increasingly sophis-
ticated needs, eventually ending in self-actualization. In his first paper, he grouped the first four
needs (physiologic, safety, love, and esteem) as “deficiency needs” (or “D-needs”) because depri-
vation in any of these categories will motivate behavior to resolve that deficiency. For example,
the individual without reliable housing will be motivated to address that deficiency prior to try-
ing to develop an artistic talent as an expression of self-actualization. Additionally, the longer an
individual is lacking in a D-need (for example, the hungrier they are), the more motivated they
will be to rectify the deficiency (greater effort to find food). In comparison, self-actualization is
not driven by a lack of something, but rather by the individual’s need to become what they can
be. Hence, this has been referred to as a “being need” (or “B-need”) and can significantly differ
from person to person. According to Maslow’s theory, as the D-needs are progressively satisfied,
an individual can address needs farther up the hierarchy until, ultimately, they can focus on
achieving self-actualization. The processes of learning may be different from the processes re-
quired to complete a task.
Figure 1.!Visual representation of
Maslow’s hierarchy of needs. The
figure above highlights the various
elements of Maslow’s hierarchy of
needs (Physiologic Needs, Safety/Se-
curity Needs, Love/Belongingness
Needs, Esteem Needs, Self actualiza-
tion needs).
Figure 2.!Dynamic trending of Maslow’s Hierarchy of Needs. The figure outlines the dynamic
natures between needs intensity and personal development and how it interfaces with the vari-
ous elements of Maslow’s Hierarchy. From Wikipedia Commons (Used under a creative com-
mons license, CC-4.0-SA).
Modern takes on this Theory
Later work, including that by Maslow himself,3 de-emphasised the rigid order of needs with the
recognition that people do not need to completely satisfy a need before pursuing another, higher
order need. Alternatively, he proposed that satisfaction of needs on numerous levels are sought
Herzberg’s two-factor theory of motivation7 arose out of studies of workplace motivation (as op-
posed to more general motivation theories of Maslow) but there are strong parallels with
Maslow’s work. Herzberg’s ‘Hygiene Factors’ align with Maslow’s deficiency needs while the
‘Motivating Factors’ align with Maslow’s being needs. However, Herzberg argued against the
idea of needs occurring along a continuum.
The level that esteem, status, and mating-related motives (e.g., mate acquisition, retention, sex,
and parenting) should occupy on the pyramid remains a topic of debate. In 2010, Kenrick and col-
leagues proposed that mating-related motives should replace self-actualization at the top of the
pyramid, adjusting the goals of the pyramid with an emphasis on propagation of humanity.8
However, the authors agreed that basic physiologic needs should remain as the base of the pyra-
Seventy-five years after Abraham Maslow’s initial publication, there remains no broadly accepted
theory of human motivation. Contemporary authors argue for the continued relevance of
Maslow’s work because it is widely recognized, continues to place human motivation at the cen-
ter of education studies, and “resonate[s] powerfully across disciplines,” whilst acknowledging
that Maslow’s hierarchy is not strongly supported by modern science.9,10 Self-actualization re-
mains an achievable and desirable goal, as our culture continues to revere those who appear au-
thentic, purposeful in their decisions, and certain in their beliefs and principles.
Other Examples of Where this Theory Might Apply
Since the early 1960s, Maslow’s hierarchy of needs has been incorporated into educational theory.
Maslow evaluates the learner holistically, taking into consideration the learner’s physical, emo-
tional, social, and intellectual qualities. It seems apparent that a learner who is unable to address
basic physiologic needs would be unable to focus in the classroom. In clinical settings, we must
consider whether clinicians have regular access to water, food, bathrooms, temperature control,
and an appropriate environment to do their work. How many times have you heard a clinician
say that they have not eaten all day because of a busy clinical shift?
A sense of safety may not translate to simply protection from the elements, but rather a sense of
security in the clinical setting as well as in the classroom. In the emergency department, this can
include the basic protection from violence, ensuring a setting that allows for appropriate patient
care with the right tools and sufficient space, and having job stability without fear of being re-
Additionally, the classroom should be a place where a student feels like they are a part of the cul-
ture and “belong”, as well as a sense that they are esteemed by their classmates and teachers. In
the clinical setting, this can translate to a clear role on a patient care team, as well as a cooperative
relationship with consultation services and between team members, in which all team members
are treated with respect.
In residency programs, the goal should be to train residents who are “self-actualized.” In this con-
text, they should be confident in their ability to perform patient care, be leaders, and advocate for
the patient. Self-actualization is unique to the individual, and it is the educator’s role to help the
learner along their individual path, rather than molding them in a certain image. The goal should
be “to facilitate the student’s discovery and actualization of their nature, vocation, what they are
good for, and what they enjoy doing.”2
As educators, if we improve working conditions, this can allow students and residents to focus
more on learning and engage them in their quest towards self-actualization.
Limitations of this Theory
Due to the nature in which Maslow’s theories were developed, it is difficult to perform replicable
testing or validity evaluations. The definition of “need” may be different between individuals.
Maslow’s sample set for biographical analysis was skewed, as it had few women, focused on
high-profile individuals, and only took into consideration cultures that were similar to his own.
Additionally, more recent data has suggested that people are able to establish meaningful rela-
tionships and obtain a sense of belongingness, or even self-actualization despite not achieving
some of the more “basic” needs as per Maslow’s definition.12
Maslow AH. A theory of human motivation. Psychological Rev. 1943;50(4):370-396.
This is Maslow’s original article, in which he outlined his five levels of needs (physiological,
safety, love, esteem and self-actualization) and the concept of pre-potency. In Maslow’s later
work, he added ‘transcendence’ as a need above self-actualization, and moved away from the
idea of a rigid, sequential hierarchy.11
DeCarvalho RJ. The humanistic paradigm in education. The Humanistic Psychologist.
1991;19(1): 88-104.
This is a good article about the work of Abraham Maslow and his contemporary Carl Rogers
with particular reference to education. DeCarvalho argues for Maslow’s humanist perspective
that an educator's true role is to unlock the potential of their students and to facilitate their
growth, enabling them to self-actualize. To do this, students must be aided in connecting to the
purpose, goal, and ultimate value of the acquisition of knowledge. True learning, from this per-
spective, is possible when it is “intrinsic, experiential, significant, or meaningful.”
Kroth M. Maslow - Move aside! A heuristical motivation model for leaders in career and
technical education. Journal of STEM Teacher Education. 2007;44(2):3.
This was written primarily for educators in the science, technology, engineering, and mathemat-
ics (STEM) fields but is easily applicable to other fields. Kroth argues that there is no universally
accepted theory of motivation and reviews numerous theories of utility to educators, while
proposing a framework which incorporates the work of Maslow and others. Kroth acknowl-
edges the limitations of Maslow's theory whilst defending its usefulness, especially as it is sim-
ple to understand and recall.
Tay L, Diener E. Needs and subjective well-being around the world. Journal of Personality
and Social Psychology. 2011;101(2), 354-365.
This was a modern evaluation of Maslow’s hierarchy of needs. The authors surveyed a sample
of participants across 123 countries searching for an association between fulfillment and subjec-
tive ratings of well-being. This study found that self-reported fulfillment was consistent across
cultures, and that fulfillment was independent of subjective well-being even when accounting
for socioeconomic status. This study argued that an individual could achieve self-actualization
without having all of their basic needs secured first.
Returning to the case...
As Ahmed sat down opposite Kerry, he looked up briefly with his tightly-drawn expression and then down
at his hands clasped in his lap.
“Ahmed, I’d like to ask you about a few things that have happened recently. I want to start by saying that
we really enjoy having you here and value you highly. It’s not easy to win over some of our nurses but
you’ve done it. However, in the last two weeks there have been instances where people have found it difficult
to work with you or found your communication unfriendly. I’d like to know your side of the story.”
Ahmed, who had been staring somewhere past Kerry’s left shoulder, rubbed his face with both hands. Final-
ly looking up, he sighed. “Doctor Kerry, I am really sorry. I know exactly the times that you are talking
about. I have already apologized to each of them and I would like to apologize to you, too. I have been really
stressed for the last three weeks as I feel like I am living in a nightmare.”
“My wife has been having trouble with her visa since leaving her engineering job and she has to leave in
two weeks. We thought she would get a spouse visa, but the immigration office wants our marriage certifi-
cate from Syria. She has tried to get her job back, but she needs a visa. Every time we speak to someone from
immigration, we are told different answers. I’ve been spending all day waiting on hold. My boards are in
less than two weeks and, if I fail again, my visa might also be in trouble.”
Kerry nodded. “Ahmed, I’m sorry. I can understand that must be incredibly stressful. We had a fellow re-
cently with a similar situation. Fortunately, the college has an incredible immigration lawyer who may be
able to help us. Let me call her for you.”
Fortunately, the immigration lawyer (Daniela) was free that afternoon. Kerry told Ahmed to take the rest of
the day off and sent him straight across the street to see her. He arrived back two hours later and poked his
head around the corner of Kerry’s door.
“Doctor Kerry?” He was smiling.
“Come in, Ahmed. How was your meeting with Daniela?”
‘Fantastic,” he said. “She said this is a common problem and that there is another visa class that we can
change to. We have an appointment tomorrow morning with the visa office. Daniela is amazing. I must get
back to my shift but thank you so much, I greatly appreciate it.”
He got up to leave but as he reached Kerry’s door he turned back. “Doctor Kerry, there is something else.”
“Yes, Ahmed?” “Daniela said that you told her that you needed her help as you wanted me to join the staff
once I passed my boards. She said it’s OK to tell me that.”
“We do Ahmed, if that’s what you want. Is it?”“Doctor Kerry, I would love that. I love my job here. My
wife and children love this city, too. We feel accepted and peaceful here. I have many ideas about contribut-
ing to your amazing team.”
1. Maslow AH. A theory of human motivation. Psychological Rev. 1943;50(4):370-396.
2. DeCarvalho RJ. The humanistic paradigm in education. The Humanistic Psychologist. 1991;19(1):
3. Maslow AH. Motivation and personality (1st ed). Harper & Row Publishers; 1954.
4. Maslow AH. Notes on Being-Psychology. J Humanist Psychol. 1962;2(2):47–71.
5. Maslow AH. The Farther Reaches of Human Nature. Arkana/Penguin Books; 1971.
6. Maslow AH. Religions, Values, and Peak Experiences. Ohio State University Press; 1964.
7. Herzberg F, Mausner B, Snyderman B. The Motivation to Work (2nd ed). John Wiley; 1959.
8. Kenrick DT, Griskevicius V, Neuberg SL, Schaller M. Renovating the pyramid of needs: Contempo-
rary extensions built upon ancient foundations. Perspect Psychol Sci. 2010;5(3):292–314.
9. Abulof U. Introduction: Why we need maslow in the twenty-first century. Soc. 2017; 54(6):508–509.
10. Kroth M. Maslow - Move aside! A heuristical motivation model for leaders in career and technical
education. Journal of STEM Teacher Education. 2007; 44(2):3.
11.Maslow AH. Motivation and Personality (3rd ed). Harper & Row Publishers; 1987.
12.Tay L, Diener E. Needs and subjective well-being around the world. J Pers Soc Psychol.
13.Wahba MA, Bridwell LG. Maslow reconsidered - A review of research on the need of hierarchy theo-
ry. Academy of Management Proceedings. 1973;1:514-520.
A Case
It’s busy Monday afternoon and the number of patients in the waiting room is only increasing. The attend-
ing is paired with a PGY 2 EM resident. Both the attending and resident are completing charts when the
triage nurse hastily interrupts stating, “This very nice woman in bed 6 appears to be having a stroke and
she’s inside the tPA window.” On impulse, the attending and resident both stand and calmly walk over to
evaluate the patient. Before them is a mid-50s appearing, well groomed woman sitting calmly in the
stretcher. The resident starts taking the history as the attending observes from the doorway. The patient
states that she is experiencing difficulty speaking and left arm weakness while she was at work. Her symp-
toms began 2 hours prior to arrival.
The resident takes a lengthy and thorough history and performs a physical examination. During the histo-
ry, the attending notices the patient is having difficulty with word finding, is unable to resist gravity in the
left upper extremity and has slight weakness in the left lower extremity. The resident turns to the attending
and states that the patient needs an emergent CT scan and places the order in the computer. The attending
reminds the resident that a set of vital signs and a point-of-care (POC) glucose are necessary prior to CT
scan. Aside from noted hypertension, the patient’s vitals and glucose are appropriate and the patient is tak-
en to the CT scanner. While the patient is in the CT scanner, the attending physician discusses the case
with the resident. The attending posits the role of thrombolytics and the resident states that if the CT scan
is negative for an acute bleed, thrombolytics may be indicated. The patient returns from the CT scanner and
radiologist calls shortly after stating the CT is unremarkable for acute pathology. The attending asks the
resident to question the patient about any contraindications she has to thrombolytics. The resident states he
is unsure of the contraindications. The attending also asks if blood pressure control is necessary as the blood
pressure is 260/130.
The resident states that he is unsure of the blood pressure goals and also states he is not sure how to best
treat the blood pressure in this patient, if necessary. The attending starts the patient on a labetalol drip for
blood pressure control. 40 minutes have passed since the patient’s arrival and it has been determined by the
treatment team that thrombolysis is indicated. After a long discussion with the patient and her family, the
decision is made to administer thrombolysis. Now 2 hours and 50 minutes following onset of symptoms,
the resident sits down to order the medication and states to the attending that he is not sure what the dos-
ing is or how thrombolytics are administered. The attending places the order. Following administration, the
patient is admitted to the critical care/neuro intensive care setting at the hospital. While both the resident
and the attending are charting, the attending physician asks the resident to reflect on the case. The resident
tells her, “I’ve really only ever taken care of one or two acute stroke patients and today was my first time
administering thrombolytics. I feel like I know a lot about stroke but I’m just not comfortable managing it
in the ED.”
Authors: Eric Blazar, MD; Vimal Krishnan, MD; Shivani Mody, DO
Editor: Daniel Robinson, MD, MHPE
Millers Pyramid
Multiple studies in medical education have demonstrated that performance on examinations
does not reflect proficiency in patient care. That is, strong written test performance
demonstrating a strong grasp of medical science knowledge does not necessarily translate to
excellent patient care.3!
Miller’s Pyramid provides a framework for assessing!clinical!competence in medical education
beyond test-taking or memorization. The pyramid, sometimes called Miller’s Triangle, can also
assist clinical teachers in matching learning outcomes with expectations of learner performance
at specific training levels. The framework, shown in Figure 1, starts with the wide base of
“knows” representing knowledge. The pyramid transitions up to “knows how” or competence.
Next, “shows how”! is demonstration of performance. Finally the ultimate point of the pyramid
is “does” or action. Miller’s pyramid demonstrates the importance of having more than just
medical knowledge, emphasizing that delivery of care is necessary for excellence in medicine.1!
The pyramid focuses on the importance of acquiring knowledge to perform a task in
practice.4!It also presents a standardized step-wise approach to clinical pedagogy and trainee
Figure 1. Millers Framework for Clinical Assessment. George Miller’s framework is often
represented as a pyramidal structure that shows the framework beginning with “Knows”
(Knowledge) at the base, and then progressing to “Knows How” (Competence), “Shows How”
(Performance), and “Does” (Action).
Created in 1990 by George Miller,1 Miller’s pyramid (Figure 1) was initially created and utilized
as a framework to clinically assess trainees at varying levels.1 Starting with “knows”, the base of
the pyramid is based on knowledge and Miller opines is the easiest to assess. Simply, standard
medical knowledge is tested through board examinations and medical school testing. These tests
are considered incomplete assessment tools in Miller’s view as he states in his original opinion
piece that medicine requires more than scientific knowledge to master excellence in medical care.
In essence, Miller emphasizes the art of medicine. Miller views knowledge as the introductory
and basis for clinical competence. Learner knowledge (”knows” stage) about tube thoracostomy,
for example, would be the ability to state indications and contraindications for placement or
demonstrate understanding of the pathophysiology of congestive heart failure (CHF).2
The second stage of the pyramid is “knows how”. This is the assessment of the ability to analyze
and interpret the data obtained or as Miller classifies, competence.1 Competence can be assessed
by testing on simulated patients or performing procedures in simulation. The US Medical Licens-
ing Examination (USMLE) clinical skills (CS) assesses this second pyramid level of competence.
The learner in this phase is able to describe the steps in placing a chest tube or discuss the steps in
managing CHF.2
The third stage is “shows how”. Miller describes this as assessing the performance of the learner
in clinical situations. Performance assessment is the learner’s ability to apply knowledge and to
analyze data when faced with a patient situation.1 Rather than working through the physical ex-
amination on a standardized patient as in “knows how”, standardized patients can be used to as-
certain not only data gathering but formulation and processing outside the clinical setting. Other
attempts at assessment of clinical performance are Objective Structured Clinical Examination
(OSCE) and Mini-Clinical Evaluation Exercise for trainees (Mini-CEX).2 Assessment on the hospi-
tal wards by clinical teaching faculty fall under the performance assessment. However, Miller
cautions against this “shows how” type of assessment as he states there is declining direct obser-
vation of the learner and most of the learner skills are interpreted during rounding or discussion
of disease etiologies.1 In the 1960/70s, studies found bedside teaching and direct observation of
the learner occurred in about 75% of patients. In contrast, Gonzalo et al in 2009 found a sharp de-
cline in bedside direct observation teaching, occurring only in about 25% of precepted patients.11
Stickrath et al found in their study, “Teams infrequently ... taught physical examination skills
(14.6%), evidence-based medicine topics (7.2%), or learner-identified topics (3.2%). Many com-
monly performed activities occurred infrequently at the bedside.”11 With this move away from
direct involvement and observation by the educator, Miller opines that assessment of the learner
George Miller
See: Miller G. The assessment of clinical skills/competence/performance. Academic Medicine.
in their ability to “shows how” is mere inference.
The apex of Miller’s pyramid is “does”. “Does” represents action and assessment of the physi-
cian’s ability to function independently in the clinical setting.1 Miller discusses that this is the
most difficult to measure. Current attempts to measure action in the clinical setting include pa-
tient satisfaction surveys, demonstration of post procedure care and other aspects including func-
tional status, cost effectiveness and intermediate outcomes.2,7
Miller’s pyramid presents a graded method of assessment for learners. In 1990, he was suggest-
ing a paradigm shift hoping to refocus medical education and stress the importance of assess-
ment outside of just knowledge. In today’s medical education ecosystem, Miller’s pyramid aids
in understanding the question we are testing and insures the assessment is valid.
Modern takes on this Theory
Since 1990, Miller’s idea has been adapted to continue to fit the changes in the field. As Miller
hoped from his original opinion piece, medicine has changed paradigms with a marked greater
focus on teaching the art as well as the science of medicine. As the learner familiarizes themselves
with concepts and skills, there is understanding that comes before having strict knowledge of the
subject. Two underpinned awareness levels, “heard of” and “knows about” have been added to
Miller’s pyramid below “know”. (Figure 2) For instance, knowing of a chest tube but not know-
ing the indications for placement is a precursor knowledge set.6
Cruess et al added a fifth level above “does”. “Is” should reflect not only clinical competence but
the presence of a professional identity.8 Medical
education evolved to consider the “attitude” part
along with knowledge and skills, which is re-
flected in Miller’s prism (Figure 3). This adds a
third dimension of professional authenticity onto
the original Miller’s Pyramid. Professional au-
thenticity focuses on “attitudes”, “skills” and
“knowledge” on a spectrum of novice to expert.
Thus, “does” with expert level attitude, skills
and knowledge is the apex of Miller’s prism
which was remodeled in 2009, nineteen years lat-
Rethans et al. recognized that both internal and
external factors influence performance and
wanted to further focus on “performance-based
assessment measuring what doctors do in actual
professional practice.”9!Thus, the Cambridge
model was created as a modern adaptation of
Miller’s pyramid.9! ! Beyond the apex of the
pyramid, “does” or competence, both system
and individual related influences will affect
physician performance.! System influences con-
Figure 2: An adaptation of Miller’s Pyramid adding
“Knows about” and “Heard of” below the other levels.
sist of any driving factor affecting or being dictated by the community. These influences consist of
guidelines, government programs, time available to spend with patients and even patient expec-
tations. All these factors influence a physician’s daily performance. Test utilization and adherence
to guideline metrics are attempts to measure daily performance. Individual influences, such as
personal and mental health and occupational relationships, will also influence the physician’s
overall performance.3,8 Thus, Rethans states that one’s individual competence plus individual and
system based external forces come together to dictate a physician’s overall performance.
Other Examples of Where this Theory Might Apply
Miller’s pyramid can be used as the transition from classroom to clinical setting. As constant
learners of new knowledge, physicians are always maturing through the pyramid from “knows”
to “does”. While on a grander scale, practicing medicine is a competency that has been divided
into specialities, Miller’s pyramid can also be used on a much smaller level. Starting on a large
scale in the US, medical students select and match into residency programs and then test in many
various ways and gain board certification for a specialty or multiple specialty practices. Individ-
ual practice and board certification are progressions up the pyramid as one becomes able to clini-
cally demonstrate mastery of a medical specialty. However, on a smaller scale the pyramid be-
comes applicable for new knowledge physicians gain at conferences or through other continuing
education to update their skills. For instance, if an older attending uneducated in ultrasonogra-
phy that already performs at a “does” level attends a workshop to develop ultrasound competen-
cy, that provider will progress up the assessment levels of the pyramid through testing, then ob-
serving and then on shift quality improvement as they improve and increase their image acquisi-
tion skills. Thus, assessment must be separated into graded measurable goals for various skills
and knowledge bases as skill mastery progresses for providers.
Figure 3: Medical education evolved to consider the “attitude” part along with knowledge
and skills, which is reflected in Miller’s prism.
Limitations of this Theory
While Miller’s pyramid has become widely utilized as the basis for benchmarking training as-
sessment and performance, as with any education theory, Miller’s pyramid does have some limi-
tations. First, Miller himself notes the difficulty in assessing “does”. To assess physicians in their
work environment while they are actively treating patients is challenging, expensive and time
consuming. The underlying test/observation would never be the same for two different
providers as no two patients, patient encounters, or care environments are the same. Thus, com-
parison becomes quite difficult when evaluating proficiency at the top of the pyramid.3,7 As case
mix and number of cases vary, complexity and attribution also contribute to the complexity of
measuring. Physicians are not the sole dictators of patient outcomes and thus only monitoring
outcomes is inherently flawed.3,7 However, at this time in health care, patient outcomes seems to
be how physician proficiency and assessment is monitored.3
The pyramid is based on the assumption that assessment in actual practice environments is a bet-
ter reflection of routine performance as opposed to preset/ artificial testing conditions.7 While
this framework is widely accepted, Miller even notes in his original manuscript that he is basing
his pyramid on conjecture. He assumes that observation in reality is a more effective truth than
simulated or testing environments.
Miller’s pyramid also is limited in that it assumes that competence predicts performance.
Demonstrating competence in the “does” apex of the pyramid is assumed to predict future good
performance. Often times, there are other influences on one’s performance. A physician or learn-
er’s performance can be greatly dictated by availability, time, energy level, mood, the environ-
ment and the patient.4
Returning to the case...
After the attending recognized the resident's significant knowledge gap in the management of acute
thrombotic stroke, the attending provided feedback to the resident the following day in an email stating that
his history was too extensive and delayed the patient’s CT scan. He also forgot to obtain vital signs and a
POC glucose. He was unable to manage the patient’s blood pressure and was unsure of many of the
contraindications to thrombolysis administration. The attending provided this feedback in a constructive
and non-threatening manner and provided resources from EM text books as well as a link to a video lecture
and a podcast to augment the resident’s learning. The attending was focusing on moving the learner from
“knows” to “knows how”.
One week later during EM didactics the resident approaches the attending stating the resources were
excellent and he feels much more confident in his acute stroke knowledge. The attending offers a simulated
case as practice to the resident. Later that day in the sim lab, the residents goes through 2 cases of acute
thrombotic stroke and displays his comfort with his new knowledge. The attending is very pleased with the
resident’s improvement and the learner has moved to “shows how.” During the debriefing from the
simulation, the attending talks about the limitations of simulation as well as the need for continued
assessment of the resident when managing acute CVA patients in the ED. They develop a way for the
resident to ask the attendings for attention and feedback when managing other acute stroke patients on shift
in the ED.
Miller G. The assessment of clinical skills/competence/performance. Academic Medicine.
Miller’s original manuscript where he presents his pyramid for clinical assessment. (Knows, knows
how, shows how, does). Miller suggests that testing is antiquated and not getting to the center of neces-
sary assessment. He suggests that while testing knowledge is important, an advanced learner must
know how and then show and finally do. He suggests different manners for assessment at each level of
the pyramid.
Rethans J, Norcini J, Baron-Maldonado M et al. The relationship between competence and perfor-
mance: implications for assessing practice performance. Med Educ. 2002;36(10):901-909.
Rethans et al further expanded on Miller’s pyramid of assessment and further theorized that compe-
tence is not solely influenced by performance. Rethans demonstrates how there are both systemic and
individual external factors that play significant roles in influencing perceived and observed compe-
tence. Systemic influences include any determinant from the governing body or hospital of employ-
ment as well as government influences on health care. Individual influences, such as provider wellness
and health, mood, patient mood and wellness, among many others also equally play a role in perfor-
mance and thus competence. Rethans decided that an inverted pyramid would best show that perfor-
mance is based on competence as well as systemic and individual influences equally.
1. Miller G. The assessment of clinical skills/competence/performance. Academic Medicine.
2. as-
sessment_and_feedback_for_residents_and_students-1.pdf. Published 2019. Accessed May 1, 2019.
3. Ramani S, Leinster S. AMEE Guide no. 34: teaching in the clinical environment. Med Teach.
4. Carr S. Assessing clinical competency in medical senior house officers: How and why should we do
it? Postgrad Med J. 2004;80(940):63-66.
5. Pangaro L, ten Cate O. Frameworks for learner assessment in medicine: AMEE Guide No. 78. Med
Teac h. 2013;35(6):e1197-e1210.
6. Cheek B. The Miller pyramid and prism.
educational_theory/adult_learning/miller.htm. Published 2016. Accessed June 23, 2019.
7. Norcini J. ABC of learning and teaching in medicine: Work based assessment. BMJ.
8. Cruess R, Cruess S, Steinert Y. Amending Miller’s pyramid to include professional identity forma-
tion. Academic Medicine. 2016;91(2):180-185.
9. Rethans J, Norcini J, Baron-Maldonado M et al. The relationship between competence and perfor-
mance: implications for assessing practice performance. Med Educ. 2002;36(10):901-909.
10.Gonzalo JD, Masters PA, Simons RJ, Chuang CH.Attending rounds and bedside case presenta-
tions: medical student and medicine resident experiences and attitudes. Teach Learn Med.
11.Stickrath C, Noble M, Prochazka A, et al. Attending rounds in the current era: What is and is not
happening. JAMA Intern Med. 2013;173(12):1084–1089.
A Case
Matt is an Emergency Medicine intern preparing for this week’s conference. He attempts to watch one of
the suggested Free Open-Access Medical Education (FOAM) videos about diabetic ketoacidosis (DKA)
while washing the dishes and keeping an eye on his 12-month-old daughter. He finished the video twice but
each time he finds that he can't remember anything. Matt feels frustrated because he knows that he’s at-
tempting to do three things at once and doing them all poorly. Between his clinical responsibilities and try-
ing to keep things going around the house, he rarely gets time alone to study. He’s worried that the only op-
tion is going to conference unprepared, neglecting his daughter, or switching to take out meals. He ponders
his dilemma and realizes that the main issue isn’t necessarily needing more time, but figuring out some
way to process everything more efficiently.
Christopher Wickens created the multiple resource theory model to explain why some tasks are
easier to do simultaneously (walking and chewing gum) while others are much harder (talking
and reading). He recognized that several different schools of thought were attempting to explain
the same phenomenon in different ways.
Historical explanations of dual-task performance relied on the mechanical analogy of workload
and power. As computers became more popular, the conception of learners having a central pro-
cessor also became popular. Kahneman’s 1973 book, “Attention and Effort,” attempted to explain
human performance using a general pool of mental “effort” without differentiated resources.2
Other scientists in the field (Isreal, Wickens, Chesney, & Donchin) noted that resources seemed to
be specialized, as the nature of simultaneous tasks affected our ability to do them. In an expan-
sive review of the literature, Wickens attempted to reconcile these theories and integrate the ex-
perimental literature.
Wickens posited that tasks compete for a shared pool of resources. Simultaneous tasks that re-
quire similar resources may interfere with each other (e.g. reading a book while listening to an-
other book). Performing two tasks simultaneously will usually reduce the efficiency of each task,
however this effect is not the same for every task or every operator. In general however, tasks are
easier to perform and most efficient when done without competing demands. Even listening to
music (which requires few cognitive resources) while driving creates occasional moments when
Authors: Matt Zuckerman, MD; Alison Hayward; MD, MPH
Editor: Benjamin Schnapp, MD, MEd
Multiple Resource Theory
Christopher Wickens.
Other important related authors or works:
Daniel Kahneman
David Boles
David Strayer
Multiple resource theory attempts to describe the demands placed on an operator simultane-
ously performing multiple tasks. Why is it easier to do some things simultaneously, while oth-
ers interfere? Why do we turn down the radio when we’re lost in the car but not when we’re
eating? The difference lies in how much processing each activity requires and whether they re-
quire similar resources. Tasks that require high levels of processing or similar resources (input
channels, motor responses) will be done less efficiently simultaneously. Improved efficiency can
be obtained by separating the overlap.
One example is pulse oximeters that warn of low oxygen levels or pulse rates with changing
audio tones while an operator is looking at an airway and using muscle memory to place an
endotracheal tube. Our brain localizes processing of different media to various areas (vision in
the occiput, auditory processing in the temporal lobe). As such, we can monitor visual and au-
ditory channels simultaneously without a serious degradation in efficiency. Researchers have
demonstrated that brain lesions localized to the visual cortex vs the auditory cortex can have
divergent effects on processing pictures vs sounds. The example of the pulse oximeter uses
these divergent pathways to increase the amount of information we are able to process simulta-
The degree of processing required is a result of task complexity or operator experience and also
has an effect on the example above. An experienced intubator notes a grade 3 view of the vocal
cords and immediately adjusts the laryngoscope to improve to a grade 1 view. This muscle
memory is gained through countless hours of consciously adjusting the laryngoscope to see
whether raising or lowering the blade improves the view. Those same hours may be spent
learning to drive. A student driver will have difficulty talking and driving simultaneously, but
an experienced driver will have little difficulty. Alternatively, the experienced driver can safely
listen to the radio but would be foolish to watch a movie while driving.
Christopher Wickens, the originator of multiple resource theory, lays out the principles that de-
fine multiple resource model architecture: demand, resource overlap, and allocation policy.
These principles are used to change the characteristics of the particular activities that are being
done simultaneously. These characteristics can include stages of processing (encoding inputs,
processing them, responding), modalities (visual or auditory), responses (manual or vocal) or
coding (spatial or verbal).1
the driver is focused on the music to the exclusion of the road, or is focused on navigating and
misses part of a song. In a multitasking scenario, the reduction in efficiency resulting from per-
forming any given tasks simultaneously is known as task interference.3,4
Modern takes on this Theory
The modern ubiquity of mobile phones increases the tendency to multitask as we constantly
respond to texts or lookup information while driving, walking, or engaging in live meetings. This
ubiquitous source of work and pleasure is an unanticipated driver of multitasking, not conceived
of when Wickens wrote his paper in 1981.
Based on experimental testing of multiple resource theory, Boles has suggested adding tactile
input (haptics) as a separate modality of input apart from visual and auditory. For example, pilots
that are focusing on a visual display and listening to audio instructions perform better with
tactile warnings communicated with vibrations than with visual warnings. These researchers
point out that tactile input is an underutilized modality in the design of safety alerts, which tend
to rely heavily on visual attention.9 Boles additionally differentiated the auditory and visual
processing modalities, breaking auditory processing into “linguistic” and emotional”
components, and visual processing into “positional spatial” versus “quantitative” components.
For example, reviewing recent lab values in chart format likely requires different visual resources
from reviewing a spreadsheet of numbers.10,11 Practically, this means we can actually process
more information simultaneously if we more effectively understand how to separate the input
channels. Cognitive load has also been found to occur in potentially unexpected places. For
example, it has been observed that visual information can create more interference based on
distance in space. If information must be gathered from different sources that require only eye
movements, this would cause a lower level of visual interference than information that requires
head movement to acquire.8
Other Examples of Where this Theory Might Apply
This theory has important implications for medical education as learners are frequently asked to
perform multiple tasks simultaneously. Consideration should be given to multiple resource theo-
ry when planning any lecture or workshop, in order to optimize the use of inputs while minimiz-
ing task interference for learners. For example, any potential distractions should be avoided
while learners are heavily cognitively engaged with learning a new procedural skill, as learners
will have few cognitive resources to spare. The theory also supports the idea of multimedia edu-
cation, as communicating information through different channels helps learners activate multiple
areas of the brain and avoid cognitive overload.
Multiple resource theory can also help explain the task efficiency learners gain when procedural
tasks become more automatic and require less processing. The surgical intern who must focus
solely on tying her knots becomes the senior who can tie knots effortlessly while monitoring
bleeding and case progression. It can also help explain why the ED provider can passively moni-
tor the ambient audio conversations of the charge nurse and simultaneously visually review the
CT scan on a trauma patient.
Modern high fidelity simulation design should factor these concepts into simulations. Requiring
a provider to handle multiple patients at once or monitor vital signs while EMS gives report re-
flect the demands on multiple cognitive resources that are placed on a provider in the real world.
Simulating scenarios in which interruptions in care take place helps trainees to practice and im-
prove on handling and prioritizing multiple types of input at the same time. Studies suggest that
high stress and high cognitive load situations with frequent interruptions may result in signifi-
cant medical errors.12, 13, 14 Through simulation exercises and through senior shifts acting as at-
tending physicians, residents can develop strategies to manage and decrease the cognitive load
and optimize their multitasking abilities.
The model also has important implications for clinical practice and contributes to how we present
information on patient monitors and in electronic medical records. Design of safety-related alerts
must take into account that using different resources will likely increase staff responsiveness to a
potential error or problem. For example, some monitors use flashing lights, rather than just audi-
tory stimuli, to indicate a concerning event. Using tactile vibrating phones that specifically alarm
for critically ill patients could increase responsiveness when compared to adding yet another
beeping machine to the hospital environment. Color-coding labs or vital signs that are abnormal
or providing the option of displaying values in a graphical format helps to highlight the abnor-
mal values by engaging different parts of the brain and increases likelihood of providers taking
note and responding appropriately.
Limitations of this Theory
The limitations of multiple resource theory include variability in measuring efficiency of tasks, as
well as the challenge of estimating a ‘baseline’ level of demand for tasks, since the level of de-
mand for a given task may be very reliant on the experience level of the individual in question
with the task.15
The multiple resource model assumes that resources will be deployed logically and optimally
towards each task being completed. More recent studies suggest that this may not be the case:
there are tasks which are more engaging than others, such that they override other tasks. Studies
have found that drivers became so engrossed by cell phone conversations that they failed to con-
tinue to pay attention to their surroundings, despite the fact that there is little overlap in resource
allocation between the two tasks.3,16,17
Returning to the case...
Matt realizes that he is struggling to process visual inputs from his FOAM video while simultaneously
looking at the dishes and his daughter. He instead finds an audio FOAM resource on DKA that he listens to
while singing to his daughter about DKA and washing the dishes. In this way he separates visual from au-
ditory inputs and reduces his mental load thinking about what his daughter is doing by entertaining her
with a fun song. He also reinforces the material he is learning through simultaneous repetition. By the time
he is done with the podcast, the dishes are clean, his daughter is ready for bed, and he is prepared for his
conference small group on DKA.
Wickens CD. Processing resources in attention. in Parasuraman R and Davies R, eds. Varieties of at-
tention. New York, NY: Academic Press,1984.
Wickens’ seminal paper on multiple resource theory discusses historical views of the source of vari-
ance in time-sharing performance and the formulation of a “performance resources function” that de-
scribes the relationship between the quality of performance and the quantity of resources invested in a
task. The applications of multiple resource theory are detailed in practice.
Wickens CD. Multiple resources and performance prediction. Theoretical issues in ergonomics sci-
ence. 2002 Jan 1;3(2):159-77. The theory is approached from the perspective of its predictions for task
interference dependent on the cognitive modality used. For example, will reviewing a map while dri-
ving affect the operation of the vehicle and will placement of that map on a heads up display modulate
this interference? The multiple resource model is reviewed in detail, with a focus on how the compo-
nents of each dimension of the model may affect one another in either creating or avoiding task inter-
ference, thus affecting time-sharing ability, and, ultimately, performance.
Wickens CD. Multiple resources and mental workload. Human factors. 2008 Jun;50(3):449-55.8:
In this paper, Wickens details the origins of the multiple resource theory. He describes additional re-
search done since his seminal paper on the subject and how it has bolstered as well as challenged the
theory. He describes the related but distinct concept of mental workload, reporting that the multiple
resource theory is most relevant to performance breakdowns related to dual-task overload. Multiple
resource model architecture consists of three components: demand, resource overlap, and allocation
policy; whereas, mental workload focuses mainly on demand regardless of whether there are multiple
tasks occurring.
1. Wickens CD. Processing resources in attention. in Parasuraman R and Davies R, eds. Varieties of atten-
tion. New York, NY: Academic Press,1984.
2. Kahneman D. Attention and Effort. Englewood Cliffs, NJ: Prentice-Hall;1973.
3. Pashler, H. Dual Task Interference in Simple Tasks: Data and Theory. Psychological Bulletin. 116(2):220–
4. Wickens CD, Sandry D, & Vidulich, M. Compatibility & Resource Competition. Human Factors,
5. Wickens CD. Processing resources and attention. Multiple-task performance. Mar 2;1991:3-4.
6. Boles D. Multiple Resources. International Encyclopedia of Ergonomics and Human Factors, Vol 3.
7. Wickens CD. Multiple resources and performance prediction. Theoretical issues in ergonomics science.
2002 Jan 1;3(2):159-77.
8. Wickens CD. Multiple resources and mental workload. Human factors. 2008 Jun;50(3):449-55.
9. Sklar AE, Sarter NB. Good vibrations: Tactile Feedback in Support of Attention Allocation and Hu-
man-Automation Coordination in Event-Driven Domains. Human Factors. Human Factors. 1999
Dec 41(4),543–552.
10.Boles DB, Law MB. A simultaneous task comparison of differentiated and undifferentiated hemi-
spheric resource theories. Journal of Experimental Psychology: Human Perception and Performance. 1998
11.Boles DB. Lateralized spatial processes and their lexical implications. Neuropsychologia. 2002 Jan
12.Pawar S, Jacques T, et al. Evaluation of cognitive load and emotional states during multidisciplinary
critical care simulation sessions. BMJ Simul Technol Enhanc Learn. 2018 Apr;4(2):87-91.
13.Li SY, Magrabi F, et al. A systematic review of the psychological literature on interruption and its pa-
tient safety implications. J Am Med Inform Assoc. 2012 Jan-Feb;19(1):6-12.
14.Ratwani RM, Fong A, et al. Emergency Physician Use of Cognitive Strategies to Manage Interrup-
tions. Ann Emerg Med. 2017 Nov;70(5):683-687.
15.Wickens CD & Boles D. The Limits of Multiple Resource Theory. University of Illinois Engineering
Psych. Lab Tech Report; Nov 1983.
16.Strayer DL, Drews FA. Cell-Phone–Induced Driver Distraction. Current Directions in Psychological Sci-
ence, 2007;16(3),128–131.
17.Strayer DL, Johnston W. Driven to distraction: dual task studies of simulated driving and conversing
on a cellular telephone. Psychological Science,12,462-466.
A Case
A new intern is managing a patient with hypotension and tachycardia. The patient is ill-appearing but alert
and conversant. The intern recognizes that this is a sick patient in shock. Her attending asks her what type of
shock she thinks this is, as each type of shock is managed somewhat differently. The intern is feeling
overwhelmed, and the only type of shock she can think of is septic shock. She understands that the definition
of shock includes inadequate end-organ perfusion, but she has difficulty coming up with other types of shock
(e.g. hypovolemic, cardiogenic, neurogenic). The attending is wondering how best to utilize this situation as
a teaching opportunity for the intern to learn other types of shock.
Prototype theory was first proposed by Eleanor Rosch in 1973 after studying how the Dani people
in New Guinea classify colors. Their language does not include specific names for colors and
instead categorizes them on a spectrum of dark/light or cool/warm. However, they were still able
to communicate their ideas of color despite the lack of exact names for colors. This inspired her to
investigate how different cultures categorize different ideas. 7, 8 Thus, the prototype theory was
formed. This was in contrast to the classical theory of categorization, which involved defining
features to rule in or rule out resemblance. The prototype theory takes a clustering approach with
the central idea/theory serving as a prototype; radially affiliated concepts can closely or loosely
resemble the prototype. This concept addressed an inherent problem within classical theory: often
times, definitions were not always agreed upon.
Within the prototype model, even loose associations are tolerated, allowing a broader range of
concepts to be included. One large benefit of the prototype theory is that retention often increases
as there is a graded concept of relatability2. An interesting aspect of prototype theory is that it can
be applied to many different fields including psychology, linguistics, mathematics, medicine,
philosophy, and even quantum physics. One of the most recent advances in this theory involved
application within the field of quantum physics; mathematical quantification was used to define
“data on conceptual combinations.” This application attempted to quantify the “relatedness” of
various concepts that were radially related based on the prototype theory.
Authors: Meenal Sharkey, MD FACEP, Mary Bing MD, MPH, Kimberly Schertzer, MD
Editor: Anne Messman, MD, MHPE
Prototype Theory
Eleanor Rosch
From the field of Cognitive Science, prototype theory is based on a conceptual organization for
categorizing various items based on common features. A prototype is “an original model on
which something is patterned.”(Merriam-Webster Dictionary) The features of a prototype are
not necessarily defining features, but more of a resemblance that can be related to all the items
within the family. If a prototype were placed in a family tree, it would be at the top and every-
thing would descend from that prototype. In contrast, classical theory requires that all items
meet a distinct criteria for membership in a particular group. That is, it either belongs or it
doesn’t. The boundaries for membership are distinct. To be in the category, it has to be clearly
defined and mutually exclusive. In prototype theory, the boundaries can be “fuzzy.”1
In prototype theory, some items resemble a “prototype” more than others. There is not usually a
single defining feature that is required for an object or idea to be included in the grouping, but
certain objects and ideas “embody” the classification more so than others. That is, the most cen-
tral member serves as the best example of that category. For instance, under the classification of
“clothing,” the item of a shirt more often embodies this concept than say, a cumberband, how-
ever a cumberband would still be included within this grouping.2 Within the realm of educa-
tional theory, prototype theory also can represent organization of ideas that have shared charac-
In medicine, patients present with a chief complaint or constellation of symptoms rather than a
definitive diagnosis. For example, a patient might complain of a bloody cough. We know the
differential diagnosis for bloody cough is broad and can include pneumonia, malignancy, pul-
monary embolism or tuberculosis, to name a few. Let's presume we use classical theory and as-
sign “bloody cough” to the pulmonary embolism category. Then you could only have a pul-
monary embolism if you also had a bloody cough. We know this would cause us to miss poten-
tially serious causes of disease and potentially misdiagnose or mismanage the patient. Since, in
reality, one symptom can fit into multiple categories, prototype theory lends itself better than
classical theory to develop a concept of disease categories in order to facilitate the learning and
problem-solving process in clinical decision-making within medicine.4
Modern takes on this Theory
In medicine, Bordage et al4 performed experiments which demonstrated that learning medical
concepts is easier when key disorders are studied within a category and then extrapolated out,
rather than learning every single diagnosis within a disease category. Papa et al6 found that use of
prototype theory can improve medical student diagnostic abilities and can be used to develop
student clinical skills with a carefully designed curriculum.
Other Examples of Where this Theory Might Apply
Relating various treatment plans to the “most common” presentation.
A stable patient with atrial fibrillation and rapid ventricular response with unknown onset
can be managed with treatment of the underlying cause and medication such as calcium
channel blockers, beta-blockers, or possibly digoxin. Extrapolating from this as the “proto-
type”, a stable patient with atrial fibrillation and rapid ventricular response with known on-
set can be managed with synchronized cardioversion. Conversely, an unstable patient with
atrial fibrillation and rapid ventricular response can also be managed with synchronized
cardioversion but with additional risk for stroke and the need for possible medical man-
agement afterwards. This is a great learning tool for interns and second years to build off
what they know based on their current curriculum and expand upon it.
Speed up diagnostic processes
In the clinical setting, the prototype theory (with semantic knowledge) can aid in the speed
of retrieval of the information for illness scripts. This is related to how we categorize various
illnesses upon initial evaluation and may have implications for how we recognize a similar/
dissimilar patient presentation and fit it within a disease category.
Limitations of this Theory
One limitation of this theory is related to the lack of defining characteristic that unifies a
particular family of concepts. This can make the associations seem nebulous and ill-defined.
Secondly, the organization of concepts is specific to an individual and sometimes even specific to
a culture.9 For example, asking someone to categorize various fruits might be different in Africa
compared to Northern Europe. Or, alternatively, categorizing various types of clothing would be
different in India and in Brazil. Another limitation includes the requirement for a shared, minimal
foundation of knowledge. If the original properties of an idea or concept aren’t agreed upon, it
will not be possible to link them through groups using prototype theory. For example, in the
initial vignette, if the intern did not know what shock was, then there would be no initial starting
point from which to break shock down further. Also for diseases that are very unusual or rare, it
may be difficult to come up with a diagnosis when it’s so dissimilar to a set prototype.
Aerts D, Broekaert J, Gabora L, Sozzo S. Generalizing Prototype Theory: A Formal Quantum
Framework. Frontiers in psychology. 2016;7:418.
This paper attempts to mathematically quantify the relationships between words and concepts. One of
the challenges is the “creative flexibility” that is inherent to the prototype theory. This paper was inter-
ested in the “conceptual distance” between the example and the prototype. This paper is a summary of
the mathematical advancements in capturing the framework of concepts within the prototype theory
and the interplay between them. The authors developed an approach called the State Context Property
(SCoP) formalism. They used participants to assign “membership weights” and “typicalities” to certain
concepts and derived equations to show this likeness. Advanced quantum mechanics were utilized to
further assess these relationships. This paper was interesting as it attempted to mathematically distill
the many variables that go into defining and quantifying what appears to be an inherent relationship
within human language. It also showed modern day application to a learning theory that has been
around for decades.
Bordage G, Zacks R. The structure of medical knowledge in the memories of medical students and
general practitioners: categories and prototypes. Med Educ. 1984 Nov; 18(6):406-16
This paper conducted four experiments on preclinical medical students vs experienced general practi-
tioners: 1) “to determine whether the concept of prototypes is applicable to the structure of selected
categories of medical disorders as stored in physician memory,” and 2) “to describe to influence of clin-
ical experience on these structures.” This study finds that Prototype view and memory of categories of
disease were found in both the preclinical medical students and experienced doctors despite a dis-
parate amount of training. This paper further suggests that medical educators should design medical
school curriculum with Prototype theory in mind.
Papa FJ, Li F. Evidence of the preferential use of disease prototypes over case exemplars among ear-
ly year one medical students prior to and following diagnostic training. Diagnosis (Berl). 2015 Dec
Diagnostic accuracy is difficult with the ill-defined nature of human diseases when individuals can
have different signs and symptoms for the same disease process. The authors conducted studies on
first year medical students through the use of Exemplar and Prototype theories (System I thought pro-
cessing) to formulate a training exercise in order to improve their diagnostic accuracy and also to de-
termine if Exemplar or Prototype theory is used preferentially for diagnosis. The authors conclude that
the training exercise improved the students’ diagnostic acumen and found that they preferentially
used Prototype over Exemplar theory for diagnosis.
Returning to the case...
The intern is overwhelmed by caring for the sick patient and trying to come up with other causes of
shock. Her attending reminds her of the other types of shock, and while septic shock might be the
“prime” example of shock (due to high prevalence in clinical practice), there are characteristics of
each of the other types of shock that make them all recognizable under the umbrella of shock. After
the patient is stabilized, the intern has now learned to classify the other types of shock, but as she is
most familiar with septic shock, it serves as the “prototype” of shock for her learning. She relates all
other types of shock to this example, and notes their differences and similarities. This allows her to
learn additional concepts of shock by using a pre-existing framework. As her attending, you
determined her “prototype” for a clinical concept to assess the basis of her understanding as the
starting point for the other types of shock. This can help solidify the intern’s understanding by
starting with a concept the intern is familiar with and expanding on related concepts.
1. Zadeh LA. A note on prototype theory and fuzzy sets. Advances in Fuzzy Systems — Applications
and Theory Fuzzy Sets, Fuzzy Logic, and Fuzzy Systems. 1996:587-593.
2. Aerts D, Broekaert J, Gabora L, Sozzo S. Generalizing Prototype Theory: A Formal Quantum
Framework. Frontiers in psychology. 2016;7:418.
3. Margolis E. Concepts: Core Readings. Cambridge Mass.: MIT Press; 2000. 390
4. Bordage G, Zacks R. The structure of medical knowledge in the memories of medical students and
general practitioners: categories and prototypes. Medical Education. 1984;18(6):406-416. doi:10.1111/
5. !Cognitive Psychology and Cognitive Neuroscience/Knowledge Representation and Hemispheric
Specialisation. Wikibooks. Available at: (
Accessed January 11, 2022.
6. Papa FJ, Li F. Evidence of the preferential use of disease prototypes over case exemplars among
early year one medical students prior to and following diagnostic training. Diagnosis.
2015;2(4):217-225. doi:10.1515/dx-2015-0024.
7. Eleanor Rosch. Wikipedia. Available at:
rization_and_prototype_theory. Published May 21, 2019. Accessed July 24, 2019.
8. Rosch EH. Natural categories. Cognitive Psychology. 1973;4(3):328-350.
9. Geeraerts, Dirk. (2016). Prospects and problems of prototype theory. Diacronia. 10.17684/i4A53en.
A Case
Melissa is a new emergency medicine intern. Her medical school grades and evaluations were excellent and
she is well-liked by colleagues, faculty, and staff. However, since starting residency, Melissa has struggled
with regard to her clinical performance.
After some critical shift evaluations, her residency director meets with her. When asked what abilities and
characteristics make a good doctor, Melissa has a hard time coming up with specific attributes. She states
that learning was easier in medical school as she was able to monitor her success through her performance
on regular quizzes and exams. Now, in residency, there are no grades and the expectations are higher. She
wants to step up and succeed but she is not sure where to start.
We can all relate to the difficulties Melissa is facing. Many of us can also relate to the challenges her resi-
dency director faces as they work to help Melissa achieve her goals. In this chapter, we will take a look at
education theory and take a deep dive into the key elements of self-regulated learning. We will discuss how
self-regulated learning techniques can be utilized by both residents and educators to achieve their academic
Self-regulated learning theory is often confused with metacognition and self-directed learning.
Metacognition was first introduced by Flavell and described as thinking about one’s own think-
ing. Although this is an essential component of self-regulated theory,3 it differs in that self-regu-
lated theory incorporates knowledge of cognition in addition to self regulatory mechanisms and
self efficacy. Moreover, self-regulated learning theory differs from self-directed learning because
in self-regulated learning, instructors provide a scaffolding and guidance for learning. In self-di-
rected learning, the process is entirely learner independent.2
Authors: Annahieta Kalantari, DO; Eric Lee, MD; David Zodda, MD
Editor: Simiao Li-Sauerwine, MD, MSCR
Self-regulated Learning Theory
Regulatory agents
The first stage of self-regulated learning is the planning phase. This is primarily done by setting
goals. Goal setting is most effective when goals are specific, individuals are committed to reach
them, individuals possess task knowledge, and individuals receive feedback on goal progress.1 In
Melissa’s case, her medical school goal was to score well on exams. She was able to develop study
plans, sustain motivation, and assess her progress in achieving goals with each exam. Her resi-
dency goal is to be a good doctor. This is not specific enough. Because it lacks specificity, she is
unable to develop an effective learning plan and is unable to assess her progress effectively.
Regulatory mechanisms
Regulatory mechanisms are under the control of the learner and are the crux of self-regulated
learning. They are:
Planning - Allows trainees to think through steps on how to achieve goals. Many are not
planned out far in advance as the plan usually evolves as the task is carried out
Monitoring Provides awareness of one’s knowledge level. Accurate monitoring enhances
the regulation of learning and reveals what the learner knows and where they need to focus
Metacognition – This differs from monitoring as it incorporates not only awareness of
knowledge but understanding one’s own thought processes.
Attention Degree to which trainees maintain cognitive focus and concentration during
Barry J Zimmerman PhD
Other important authors or works:
Susanne P. Lajoie PhD
Paul R. Pintrich PhD
Self-regulated learning theory is the process by which learners modulate affective, cognitive,
and behavioral processes throughout a learning experience to reach a desired level of
achievement.1 It was introduced by Zimmerman in 1989 as an integrated theory that addressed
the interaction of cognitive, motivational and contextual factors.2 It is made up of three basic
components: regulatory agents, regulatory mechanisms and regulatory appraisals.1 Each of
these components are described in detail below.
Learning strategies Useful for breaking a task into smaller parts and reorganizing parts
and building knowledge structures that are meaningful and can be stored in long term
PersistenceHow effort is devoted despite boredom and failures. Function of outcome ex-
pectancy. Goal setting, self-efficacy, and feedback all have positive effects on persistence.
Time management Study schedules and allocating time, meeting deadlines. Opposite of
Environmental structuring – choosing study location supportive of learning, removing dis-
tractions from study area. Imperative for online training.
Help seeking degree to which trainees ask assistance when they have difficulty under-
standing concepts. Knowing when, why and from whom to ask for help.
Motivation willingness to engage in learning and desire to learn. Beliefs about incentives
or values of learning have direct effect.
Emotion control – limits intrusion of performance anxiety. Trainees can engage in relaxation
exercises, self encouragement and self talk. Facilitates performance by keeping off-task con-
cerns at bay
Effort amount of time devoted to learning. Regulate effort by monitoring behavior and
feedback on performance. If detect negative discrepancy, will increase effort to reduce dis-
As learners engage in goal achievement, self efficacy will redirect which regulatory mechanisms
should be incorporated or require adjusting.1
Regulatory appraisals