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EDUCATION THEORY
MADE PRACTICAL
Fant | Gottlieb | Li-Sauerwine | Krzyzaniak | Natesan | Schnapp | Chan
VOLUME 5
Education Theory Made Practical: Volume 5
Published by McMaster Office of Continuing Professional Devel-
opment, Hamilton, ON, Canada.
Supported by Academic Life in Emergency Medicine,
San Francisco, California, USA.
First edition, February 2022
ISBN: 978-1-927565-47-6
This project is made possible in part with funding by the Govern-
ment of Ontario and through eCampusOntario’s support of the Vir-
tual Learning Strategy. To learn more about the Virtual Learning
Strategy visit:!https://vls.ecampusontario.ca
Available for usage under the Creative Commons Attribution-
NonCommercial-NoDerivs 3.0 Unported!License.
FRONT MATTER & COPYRIGHT
ii
A Project of the Faculty Incubator
Academic Life in Emergency Medicine
iii
EDUCATION THEORY
MADE PRACTICAL
VOLUME 5
Editors
Abra Fant, MD, MS
Michael Gottlieb, MD
Simiao Li-Sauerwine, MD, MSCR
Sara Krzyzaniak, MD
Sreeja Natesan, MD
Benjamin Schnapp, MD, MEd
Teresa Chan, MD, MHPE
This book is dedicated to all of the healthcare and other frontline workers who
have continued to make our communities function during a second year of
global pandemic. In particular, we want to recognize the tireless efforts of edu-
cators who have had to adapt and disrupt on an almost constant basis to keep
their learners moving forward.
!
Additionally, we would like to thank Academic Life in Emergency Medicine for
their continued support of the Faculty Incubator and medical educators in gen-
eral. Dr. Michelle Lin has continued to be a light and leader during this difficult
time and ALiEM resources have been a priceless trove as we have all adapted to
virtual, hybrid and other forms of education.
!
Finally, we would like to thank the members of the 2020-2021 class of the
ALiEM Faculty Incubator who have worked so diligently on creating this book,
which will help other educators understand and utilize educational theory. We
are so proud of the scholarly work you have accomplished here. We are also so
proud of everything else you accomplished during 2020-2021 while balancing
clinical responsibilities and all the additional burdens of pandemic life. We can’t
wait to see what you all accomplish next.
Abra Fant, MD, MS
Michael Gottlieb, MD
Simiao Li-Sauerwine, MD, MSCR
Sara Krzyzaniak, MD
Sreeja Natesan, MD
Benjamin Schnapp, MD, MEd
Teresa Chan, MD, MHPE
iv
DEDICATION
When I was first asked to write the foreword for this 5th volume of Education
Theory Made Practical, I jumped at the opportunity to share my thoughts about
the importance of theory in medical education. As a residency program director,
educator, researcher, and clinician, I find huge value in the interweaving of edu-
cational theory into all elements of my job, and I anticipated a relatively easy
task of communicating this value and providing a meaningful opening for the
book.
!
And then I received the list of topics. While a few theories—such as Sociocultur-
al Theory and Situated Cognition—are familiar to me, most are not.! My com-
plete lack of awareness of Banking Theory, Ausubel’s Meaningful Learning
Theory, and Constructive Alignment, among others, suddenly made me wonder
if I was the right person to write this foreword. As imposterism bubbled inside
me, I realized that my unfamiliarity with most of these theories is, in and of it-
self, why this text is so valuable. !
!
First, it brings to our attention diverse theories likely to otherwise to remain off
our pedagogical and academic radars. Indeed, a theory is only as useful as our
knowledge of its existence. For most busy medical educators, sourcing mean-
ingful theories from the seemingly infinite sea of literature—from sociology and
anthropology to psychology, education, and beyond— is simply not feasible.
And, thanks to books like this one, it’s not necessary: the authors and editors
have done it for us. In reviewing the theories presented in this and previous
volumes, I am struck by the breadth and diversity of areas covered, and I find
myself wondering: how would I have become aware of all these theories with-
out this series?
!
Second, this book takes complicated, complex, and rich theories and presents
them in high-yield, digestible fashion. For example, in her Theory of Sociomate-
rialism, Wanda Orlikowski examines complex organizational dynamics by fo-
cusing on how social and material elements of technology and organization are
enmeshed within the workplace. As a theory that grew from decades of work
and numerous existing theories, one could spend hours attempting to elucidate,
conceptualize, and understand its key elements. This level of inquisition simply
v
FOREWORD
isn’t feasible among the day-to-day demands of teaching and practicing clinical
medicine, and here again, this book shines. For each theory, the authors define key
terms, summarize conceptual origins, highlight modern advances, and review—in
annotated fashion—critical accompanying references. The net sum of this gift to
the reader is a high-level, contemporary overview that distills out the key aspects
of a given theory and provides a roadmap for readers wanting to learn more.
!
Finally, what makes this book especially valuable is the extent to which the au-
thors link the chosen theories to real-world scenarios in medical education. No-
tably, these real-world scenarios are placed at the beginning and the end of each
chapter, situating the diverse range of theories in a practical context and trans-
forming them into tools that serve the educator, the learner, and—ultimately—the
patient.
!
Does a given theory provide the best or only way to navigate the scenario pre-
sented? Of course not. But it does provide an approach, grounded in science, from
which an educator may begin this navigation and through which they may refine
the theory’s utility—or find an alternate theory that provides a better fit.
!
As we leverage the power of theory to navigate this path, we can only hope for
multiple more editions of Education Theory Made Practical to come.
Will Bynum, MD
Associate Professor of Family Medicine
Duke University School of Medicine
vi
Chapter 1: Banking Theory
Authors Eva Niyibizi, MD; Susan Fraymovich, DO
Editor Simiao Li-Sauerwine, MD, MSCR
!
Chapter 2: Constructive Alignment
Authors Sharon Bal, MD, CCFP, FCFP; Kelly N. Roszczynialski MD, MS
Editor Teresa M. Chan, MD, MHPE
!
Chapter 3: IDEO’s Design Thinking Framework
Authors: Lauren Falvo, MD; Mohammed Hagahmed, MD
Editor: Abra Fant, MD, MS; Teresa M. Chan, MD, MHPE
!
Chapter 4: R2C2 Model for Feedback
Authors: Sean Dyer, MD; Geoffrey Comp, DO
Editor: Michael Gottlieb, MD; Teresa M. Chan, MD, MHPE
!
Chapter 5: Feminist Theory
Authors: Lauren Evans, MD; Dolly Yadav, MD
Editor: Sreeja Natesan, MD; Teresa M. Chan, MD, MHPE
!
Chapter 6: Sociomaterialism
Authors: Fawziah Alsalmi, MBBS; Lorne Costello, MD, MSc; Kristine Prince, DNP, APR
Editor: Sara M. Krzyzaniak, MD
!
Chapter 7: Logic Model of Program Evaluation
Authors: Kathryn Fisher MD, MS; Jeanne Macleod, MD; Sarah Kennedy, MD
Editor: Benjamin Schnapp MD MEd; Teresa M. Chan, MD, MHPE
!!!!!!!!!!!
Chapter 8: Situated Cognition
Authors: Drew Kalnov, DO; Jennifer Whitfield, MD; Sophia Lin, MD
Editor: Abra Fant, MD, MS; Teresa Chan, MD, MHPE
Chapter 9: Ausubel’s Meaningful Learning Theory
Authors: James Hoffman, MD; Riccardo Bianchi, PhD; Muhammad Durrani, DO
Editor: Michael Gottlieb, MD
Chapter 10: Sociocultural Theory
Authors: Tabitha Ford, MD; Mala Joneja, MEd, MD; Anna Bona, MD
Editor: Sreeja Natesan, MD
vii
TABLE OF CONTENTS
viii
ABOUT THIS BOOK
Education There’s Made Practical (Volume 5) 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 (aliem.com) and the In-
ternational 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
practice.
Each chapter has been written and edited by clinician educators for clinician educators,
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 discussion of the featured theory
itself, its modern applications, and finally the case is closed by articulating how the theo-
ry could augment education practice. Additionally, we include an annotated bibliography
so that readers can easily 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 Govern-
ment 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.
Purpose
The Education Theories Made Practical eBook series was designed to provide 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 resource for identifying further relevant lit-
erature.
ix
Funding
This work has been funded by a generous grant from eCampus Ontario, which is an
initiative of the Government of Ontario (Canada).
Usage
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 (aliem.com/library), Apple Bookstore,
ResearchGate, and the Government of Ontario’s eCampus library.
Editors
Abra Fant, MD, MS
Michael Gottlieb, MD
Simiao Li-Sauerwine, MD, MSCR
Sara Krzyzaniak, MD
Sreeja Natesan, MD
Benjamin Schnapp, MD, MEd
Teresa Chan, MD, MHPE
Foreword
William Bynum IV
A Case
Sarah was excited to start medical school. Her road to medical school was not the typical one. When she attended
college, she majored in biology and had expected to work as a basic science researcher. She completed her master’s
degree in biology and even worked in the university lab for two years. She ultimately decided her passion was in
medicine and after going back to school to complete her requirements, she was finally starting medical school.
Sarah’s first month in medical school did not live up to her expectations. She found her physiology class boring
and repetitive. Her class was held in a large auditorium with four hundred first-year medical students feverishly
taking notes while the professor stood in the front of the classroom lecturing. She was disappointed that there were
no engaging conversations or exchange of ideas during class time, as she had during her seminar classes during
college.
Sarah had an advanced biology degree and the material being covered in class was something she herself had al-
ready taught while being a teacher’s assistant in graduate school. Sarah felt like she didn’t have an opportunity to
share her knowledge nor develop additional skills in this type of learning environment. Sarah was frustrated. Is
this what medical school was going to be like for the next four years?
Background
Paolo Freire was a Brazilian educator, socialist, activist (1921-1997). Freire's theory is based on a Marxist
approach and his view of anti-colonialism stemming from his poor upbringing in Brazil. He believed his
country’s population needed to have increased access to education. Education, when done the right
way, would empower the repressed to regain their sense of humanity and overcome their poor
conditions. Freire’s Banking Model viewed educators as oppressors who teach students to conform to
their way of thinking. Students are oppressed and learn their place in society through their
teachers.They do not ask questions and accept what they are being taught; they are passive learners who
learn by repeating facts without using critical thinking skills. The teacher deposits knowledge directly to
the student and the student is expected to memorize it exactly as it is being taught. This method does
not facilitate free thinking or transformative thought. Freire argues instead that the utility of education is
far more than the transmission of information. Instead, he views education in the broader context of
liberation of oppressed peoples, as a tool for humans to discard the tools of oppression and liberate their
potential. A teacher, in Freire’s view, should foster learning without dictating content, while also being
open to concurrent learning themselves. A learner is continually challenged by questions posed by the teacher,
critically considers content, and is fully engaged in the creative dialogue.
10
CHAPTER 1
Authors: Eva Niyibizi MD, Susan Fraymovich DO
Editor: Simiao Li-Sauerwine, MD MSCR
Banking Theory
Modern takes on this Theory
The Banking Model is based on teachers recapitulating their knowledge directly to students as accepted
facts. There is no thought given to the background of the student or differing levels of knowledge of
those in the classroom. Students, on the other hand, play a passive role in their own education. They do
not use critical thinking or interpret the facts they are given. They are expected to memorize the content
and recite it when asked. To overcome these antiquated teaching styles, Freire suggests the teacher
should become a student and engage with students. Students come from different backgrounds of
knowledge and skill; Students can learn from each other and educators can learn from them as well.
Freire recommends problem-based learning, wherein teachers pose scenarios and allow students to for-
mulate their own questions and answers.
In recent times, Banking Theory has been considered in the context of medical education. It is true that
much of the foundational content in medical school curricula deals with a specific body of knowledge
that is critical to impart. Building upon this, proponents of Freire also assert that it is critical in medical
education to train students to have a deep understanding of the culture surrounding medicine as well as
a commitment to supporting the humanity of all people. In Problem-Posing Education, teachers should
lead by facilitating discussions and providing support, and should contribute information only after
group dialogue takes place. In this way, educators empower learners and consolidate knowledge from
shared experiences in order to translate and apply content to the real world. This approach lends itself in
particular to medical school formats such as problem-based learning, and topics such as community
health.
Other Examples of Where this Theory Might Apply
The Banking Model of imparting foundational medical knowledge is commonly seen in the first two
years of medical school curricula, where an instructor is tasked with imparting a collection of facts in a
time-constrained lecture format. In a push to combat this traditional approach, many schools are now
adopting more innovative techniques such as problem-based learning.
Much knowledge and experience is also gained during residency training. Banking Model’s converse,
Problem-Posing Education, is more frequently employed in the graduate medical education setting. Ex-
amples of forums allowing for lively discussion and shared knowledge include morning report, small
11
MAIN ORIGINATORS OF THE THEORY
Paolo Freire
OVERVIEW
The Banking Model by Paolo Freire described the teaching theory of students being “banks” for
teachers. Teachers deposit knowledge in students while students memorize and repeat what they are
taught. The teacher plays an active role while the student plays the passive role of absorbing the
information. Preexisting knowledge of the student is ignored and all students are taught on the same
level.
group discussions during resident conference, bedside teaching, and on-the-fly discussions amongst
residents and attending physicians.
Limitations of this Theory
Some students need the structure and may learn best in a banking model, especially those in the be-
ginning of their students who are learning frameworks and foundations. These students do not yet
know enough to question or engage. Some concepts also lend themselves to direct instruction such
as safety precautions in a laboratory or how to fill out a death certificate. Careful and direct instruc-
tion is necessary to avoid fatal errors.
After multiple classes in her first semester seemed to be structured the same way, Sarah had
enough. She was not learning anything new and felt herself slowly disengaging from the classroom
to the point where she was no longer showing up to class. Sarah decided to do something about it.
She made an appointment and spoke to her professor.
Returning to the case...
After multiple classes in her first semester seemed to be structured the same way, Sarah had enough. She was
not learning anything new and felt herself slowly disengaging from the classroom to the point where she was
no longer showing up to class. Sarah decided to do something about it. She made an appointment and spoke
to her professor.
At her meeting, Sarah discussed her disappointment in the classroom structure. She made it clear that she had
a lot more to add than sitting and taking notes in the back of the class. Her professor listened intently and, to-
gether, they made some changes. They instituted small group learning. Instead of the lecture- style classroom,
the entire class was split into groups of 10 people. Each group was given a topic with a question to answer.
Each group was in charge of researching their idea and formulating a series of solutions to present to the class
next week. Each team member was asked to contribute, engaging all players on the team. Sarah was able to
use her prior experience from her master’s program to help her team. In return, she was able to learn from her
team mates who were each able to bring something unique to the group due to their varied past experience.
References
1. Freire, P. (1970). Pedagogy of the Oppressed. New York: Continuum.
2. Drew, C. “The ‘Banking’ Model of Education - Pros & Cons (2021).” Helpful Professor, 28 Apr.
2021, helpfulprofessor.com/banking-model/.
3. Shor, I. (1987). Freire for the Classroom: A Sourcebook for Liberatory Teaching. New Hamp-
shire: Heinemann Educational Books.
4. DasGupta, S., Fornari, A., Geer, K. et al. Medical Education for Social Justice: Paulo Freire Re-
visited. J Med Humanit 27, 245–251 (2006). https://doi.org/10.1007/s10912-006-9021-x
5. Torre D, Groce V, Gunderman R, , et al. 2017, 'Freire’s view of a progressive and humanistic
education: Implications for medical education ', MedEdPublish, 6, [3], 5, https://doi.org/
10.15694/mep.2017.000119
12
13
ANNOTATED BIBLIOGRAPHY
1. Freire P. Pedagogy of the oppressed (revised). New York: Continuum. 1996.
This is Freire’s original text in which he outlines the 10 defining features of the Banking Model of Ed-
ucation:
1. The teacher teaches while the students are taught.
2. The teacher knows everything while the students are ignorant.
3. The teacher thinks while the students are thought about.
4. The teacher narrates and the students listen.
5. The teacher disciplines and the students are disciplined.
6. The teacher chooses and the students comply.
7. The teacher acts and the students observe.
8. The teacher sets the curriculum and the students adapt to it.
9. The teacher claims authority to oppress the students.
10. The teacher is the subject while the students are objects.
2. Drew C. The Banking Model of Education: Pros and Cons. Helpful Professor Website. Accessed
January 18, 2022. Available at: https://helpfulprofessor.com/banking-model/
The Banking Model of Education is a metaphor in which students are viewed as passive vessels in
which teachers deposit knowledge. The opposite of this model is Problem-Posing Education, in
which students learn with and from each other in problem-oriented exercises. This resource describes
the advantages and disadvantages of Banking Theory.
3. Shor I. Freire for the classroom: A sourcebook for liberatory teaching. Heinemann Educational
Books, Inc., 70 Court St., Portsmouth, NH 03801; 1987.
This book is an anthology of essays written by teachers on the application of Freire’s methods to
classroom teaching. The essays in the book describe the creative practices employed by teachers as
well as benefits to students as a result of applying Freire’s philosophy.
4. DasGupta S, Fornari A, Geer K, Hahn L, Kumar V, Lee HJ, Rubin S, Gold M. Medical education
for social justice: Paulo Freire revisited. Journal of Medical Humanities. 2006 Dec 1;27(4):245-51.
This publication frames the work of Freire in the context of incorporating social justice curricula in
medical education. The authors posit that Freire’s non-hierarchical strategies can foster socially con-
scious medical professionals who are engaged in their communities.
A Case
Claudia has just become a new pre-clerkship curriculum coordinator for a prominent medical school. The
program is currently undergoing curriculum renewal, and she has been tasked to advise on pedagogy that
will ensure optimal student engagement and deep learning. She is provided a list of learning objectives that
need to be covered throughout the pre-clerkship, as well as a document indicating “where and when” in the
curriculum each topic is taught in the first two years. She is told that the medical school strategy is to mod-
ernize the curriculum as they move away from largely didactic teaching, but are not clear on where they
want to land.
Claudia was just considering this project when she gets a call from a former medical school classmate,
Michelle, reminiscing about their trials and tribulations of undergraduate medicine.
Remember when we just gave up studying and learned to memorize old tests? Man, I
wished I’d known back then that CribNotes is all I needed for clerkship, I would have had
so much less stress. It was like all the surgeons took their pimping questions straight from
the book...
Claudia’s amusement quickly changes to chagrin as she realizes, her scope involves not just considering
learning theory, but also providing instructions as to how best to align current curricular components such
as assessment to ensure defined learning outcomes. She is cognizant that medicine is no longer simply
about transmission of a body of knowledge, but about acquiring the skills to problem-solve and address
gaps. She will need to consider these learning outcomes, and recommend the teaching activities and as-
sessments that indicate success...wow, this was going to be a challenge!
Background
14
CHAPTER 2
Authors: Sharon Bal, MD, CCFP, FCFP ; Kelly N. Roszczynialski MD, MS
Editor: Teresa M. Chan, MD, MHPE
Constructive Alignment
15
MAIN ORIGINATORS OF THE THEORY
John B. Biggs
Other important authors or works:
Catherine Tang
OVERVIEW
“Constructive alignment” can be broken down into two components. The first is based on
constructivism, the idea that learners construct their knowledge from learning activities that they can
integrate and build upon their current belief system (meaning) and prior experience. Knowledge is not
directly passed from teacher to learner, rather the learners must engage and create new meaning for
themselves. The second component is alignment: the objectives, teaching activities, and assessment
that support the learning. The intended learning outcomes are the driving force to then determine
appropriate assessment strategy and finally align the teaching activities to the intended outcomes as
well as the assessment tool.
Constructive alignment (CA) differs from the theory of criterion-referenced assessment which aligns
assessment to objectives in that it also includes aligning the teaching methods with the focus on in-
tended learning outcomes (ILOs). The goal of constructive alignment is to support students in devel-
oping meaning and learning from a considered, well-designed and aligned course.
In constructive alignment, as described by originator Biggs1, one must consider teaching and learning
to be a whole system2:
Medical education since the turn of the last century was rooted in the reductionist, biomedical mod-
el of medicine itself. It was this tradition of hierarchy that determined that the role of teacher (mir-
roring that of physician) was, to a large extent, that of omniscient content expert. There was a large,
but somewhat finite lexicon and inventory of factual knowledge, which learners were expected to
master during their studies in medical school and subsequent training. The role of learner was, in
this respect, more passive and the teacher’s role was to transmit this body of knowledge to the stu-
dent.3
In recent years, educational theories based in cognitive learning theory4 in support of active learning
and less hierarchical paradigms have grown increasingly the norm in medical education. In con-
structivist alignment theory, the role of the teacher changes4 from transmitting knowledge to assist-
ing learners in their own critical self-reflection. And, similarly, the locus of learning for the student
has gone from an external to an internal one. The emphasis on the experiences and meaning in the
construction of knowledge further moves away from the generalism of the didactic or traditional
curricular design by acknowledging individuality in knowledge acquisition. It is the latter that
makes the “alignment” of appropriate teaching activities to ensure student engagement, along with
appropriate assessment tools, key to achieving the intended learning outcomes1,2 (ILOs). Modern
takes on this Theory. Another key component of this theory, as described by Biggs in his 1996 article,
is that constructive alignment comprises a whole learning system, which embraces “classroom, de-
partmental and institutional levels.” He contrasts CA with poorly designed systems in which cur-
ricular components such as teaching and assessment are not integrated as a unified process. For ex-
ample, a psychiatry course on critical analysis that uses multiple choice tests as a final assessment,
which does not test the students ability to display their logic or thought process. In fact, essential to
CA is the outcomes-based approach2 to teaching, the ILOs then define both the instruction and as-
sessment. In this way, CA itself requires significant investment and energy to fully implement the
learning environments, by starting with what we want students to know by defining the intended
learning outcomes, we then align teaching and learning activities, and assessment plans.
Intended learning outcomes differ from traditional learning objectives in that they are demonstrable
and focus on application and higher level learning as opposed to focusing on discrete knowledge
that is being taught. ILOs must be written in such a way that they can be observed and measurable
in order to appropriately align later with planned assessment. When determining the needed teach-
ing and learning activities a distinction should be recognized, with a student centered approach,
teaching is input while learning is output. Learning activities may include traditional direct instruc-
tion, readings, lectures, or assignments that can serve as both a learning method or a mode of as-
sessment to ensure learning has been mastered. These activities may include simulations, case stud-
ies, presentations, lab work, or problem based learning.
Modern takes or advances in this theory
Outcome based medical education echos constructive alignment theory, by orienting training on in-
tended learning outcomes. As described by Biggs and Tang (2011), in outcomes-based teaching the
question changes from which topics are taught to “What do I want my students to be able to do” af-
ter curriculum completion2. Medical schools have begun implementing such learning activities as
problem based learning sessions, portfolio education exercises, and narrative exercises into under-
graduate medical education. Medical simulation has become increasingly integrated into medical
16
education at both undergraduate, graduate, and post-graduate continuing education levels and can
serve as both a learning activity with team based learning or for assessment such as OSCEs for un-
dergraduate medical education.
In more recent times of crises during the COVID-19 pandemic a need surged for education on man-
agement practices and personal protective practices across the world. Institutions have used this
same framework to first identify the learning outcomes of safe care for potential COVID-19 patients,
developed quickly implemented learning activities through teleconferences, discussions, and simula-
tions to align for assessment of these critical skills. Assessment in some settings includes auditing by
Infection Protection and Control (IPAC) experts.
Other Examples of Where this Theory Might Apply
It is important to remember when designing intended learning outcomes the three domains of learn-
ing: cognitive, affective, and psychomotor. The classroom setting may be more applicable to cogni-
tive learning outcomes such as students will be able to analyze the impact of socioeconomic status in
rural medicine. Similarly this could be designed for the affective learning domain and written as
students differentiate medical care received by patients of lower socioeconomic status in rural set-
tings. Narrative exercises could be incorporated from both ILO domains and assessment may include
case studies in the classroom setting or field work during a clinical rural medicine rotation.
Another application for constructive alignment in the clinical setting is in procedural training6. One
common intended learning outcome in the postgraduate medical education and training is safe and
effective central line placement for the critically ill patient. Other medical education theories and
modalities, such as medical simulation and mastery learning can serve as excellent teaching and
learning activities and have paired assessment with mastery learning checklist and rubric/criterion
levels for evaluation.
Limitations of this Theory
Not all of medical education takes place with a curricular design plan or in a controlled classroom
setting. In particular, the clinical rotations in medical education have a different structure for both the
teacher and the learner. While the overall clinical clerkship course may allow for an overarching cur-
ricular plan, the daily “in and out” of clinical rotations limit the reach of constructive alignment edu-
cational theory. The variety and diversity of patient presentations during clinical rotations is often
what inspires teaching topics and these change on a daily basis. Because of this inherent design of
the clinical rotations the forethought and planning that are required for constructive alignment may
not fit for every learning environment.5,6 Constructive alignment requires significant energy for ap-
propriate reflection1,3 and preparation to develop the intended learning outcomes, design the associ-
ated teaching and learning activities, and create aligned assessment. This makes constructive align-
ment a difficult modality to employ on an immediate basis.
Returning to the case...
17
After a significant amount of research, and consultation with learners and faculty colleagues, Claudia feels that the
best approach to ensuring deep learner engagement and achievement of intended learning outcomes (ILOs), would
be basing the curriculum renewal in constructivist alignment theory. In presenting to the medical school’s curricu-
lum committee, Claudia references the work done by Biggs, and how intentional consideration of teaching activities
and assessment will ensure achievement of medical education objectives.
Claudia finds an apt audience as she walks through the ways in which constructive alignment could apply to di-
verse instructional activities, including problem-based learning (PBL) tutorials, portfolio education exercises as
well as clinical activities. She describes Biggs’ distinction between declarative knowledge, and how this kind of tra-
dition best reflects her own undergraduate education, versus functioning knowledge. It is this latter, deeper knowl-
edge acquisition in our learners that should be our ultimate aim in designing curriculum. Construction of knowl-
edge, which is anchored in both experience and meaning, is key for deep learning and the independent, learner-dri-
ven creative problem-solving that the modern student requires in the ever-changing landscape of modern medicine.
The teacher’s task now becomes fostering the engagement in the material to ensure students can use their knowl-
edge - making it functional - and of use to them in their practice and increasing their confidence.4 She emphasized
that alignment of curriculum includes assessment tools to ensure objectives will be met.
She reflects on how different the incoming medical students’ experience might be from her own, and can not help
but pick up the phone to brag a little to her classmate!
References
1. Biggs, JB. Aligning teaching for constructing learning. Higher Education Academy. 2003. https://
www.researchgate.net/profile/John_Biggs3/publication/255583992_Aligning_Teaching_for_Con-
structing_Learning/links/5406ffe70cf2bba34c1e8153.pdf. Accessed: May 15, 2020.
2. Biggs, JB. Constructive alignment in university teaching HERDSA Review of Higher Education, vol.
1.
3. Biggs, J., & Tang, C. (2011). Train-the-Trainers: Implementing Outcomes-Based Teaching and
Learning in Malaysian Higher Education.
4. M Robinson, H Murray. What Can Cognitive Learning Theory Teach Us About Effective Teacher
Behaviours. REFLECTIONS 1992
5. Joseph, Sundari & Juwah, Charles. (2011). Using constructive alignment theory to develop nursing
skills curricula. Nurse education in practice. 12. 52-9. 10.1016/j.nepr.2011.05.007.
6. Loretta M Jervis & Les Jervis (2005) What is the Constructivism in Constructive Alignment?, Bio-
science Education,6:1, 1-14, DOI: 10.3108/beej.2005.06000006
7. Barrow M, McKimm J, Samarasekera DD. Strategies for planning and designing medical curricula
and clinical teaching. South East Asian Journal of Medical Education. 2010;4(1):2-8.
18
19
ANNOTATED BIBLIOGRAPHY
1. Biggs, JB. Aligning teaching for constructing learning. Higher Education Academy. 2003. Orig-
inal Theory
This summary is written by the originator of the theory itself, John Biggs, and reviews the two key
aspects of constructive alignment. It reviews the overarching steps to align intended learning out-
comes, teaching/learning activities, and assessments to create a global high-level learning system.
2. Loretta M Jervis & Les Jervis (2005) What is the Constructivism in Constructive Alignment?,
Bioscience Education, 6:1, 1-14, DOI: 10.3108/beej.2005.06000006
In this paper the authors describe constructive alignment specifically focused from the construc-
tivism perspective. They comment on the wide definition of constructivism and how its broad ap-
plicability has led to confusion particularly in science education where there is a need to distinguish
realism as a knowledge theory from constructivism as a learning theory. They critically evaluate the
application and limitations of constructive alignment and argue against its use in scientific educa-
tion.
3. Biggs, J., & Tang, C. (2011). Train-the-Trainers: Implementing Outcomes-Based Teaching and
Learning in Malaysian Higher Education.
In this paper, the authors responsible for describing constructivist alignment (Biggs) and the more
detailed implementation of this theory (Biggs and Tang) review its implementation in Malaysian
higher education using the Train-the-Trainer model. In reviewing this model, they review quantify-
ing the level of understanding being sought when stating the intended learning outcomes, distin-
guishing between declarative and functional knowledge, and state that while much of university
teaching is focused on the former (declarative) knowledge, what is required by practitioners is the
functional type as their knowledge needs to inform action. Matching the ILOs, and subsequently the
teaching and assessment methods to the knowledge type is imperative. The trainers, also, must un-
derstand constructive alignment such that principles are applied as intended.
4. Barrow M, McKimm J, and Samarasekera DD. Strategies for planning and designing medical
curricula and clinical teaching. Medical education in Practice. South-East Asian Journal of Med-
ical Education. 2010;4(1):2-8.
A brief review of curriculum developments in medical education discussing the practical applica-
tion of constructive alignment and the shift towards learner-centeredness. A case example of the
Yong Soo Lin School of Medicine revised five year undergraduate medical education is provided,
showing the practice of the theory and inclusion of teaching and learning activities such as simula-
tion, problem based learning, and team based learning. They also briefly address the gap that can
exist between the clinicians teaching in the clinical setting and those designing the curriculum, high-
lighting the need to specifically design learning outcomes to be applicable to the variable clinical
setting.
A Case
Dr. Pneumo is an assistant emergency medicine professor at Academic Hospital School of Medicine (AHSOM) lo-
cated in Big City, USA. She has recently taken over the medical student clerkship and has been tasked with updat-
ing the school’s approach to its core curriculum. Dr. Pneumo is excited to be a part of this change, but is new to
curriculum design and still figuring out how to engage her learners.
AHSOM is located in the heart of the city and serves a large homeless population. Many of these people are strug-
gling with mental health illnesses and are forced to use the emergency department to obtain many of their re-
sources. During her shifts in the department, Dr. Pneumo has become increasingly concerned by the behavior of
her learners. She has noticed that learners are joking more often about psychiatric patients, using the word
“crazy.” Other learners are frustrated with these patients, complaining that the patients are “poor historians” and
cannot focus enough to have a history or exam.
Dr. Pneumo would like to update the medical student curriculum to promote awareness of the struggles that men-
tal health patients experience. Her goal is to increase empathy and understanding for this population, so that they
may be treated with the respect they deserve. She is also hoping that this improved foundation of knowledge will
lead to better history and physical exams, and therefore better care for these patients.
With these goals in mind, how can Dr. Pneumo update the current curriculum?
20
CHAPTER 3
Authors: Lauren Falvo, MD; Mohammed Hagahmed, MD
Editor: Abra Fant MD, MS; Teresa Chan, MD, MHPE
IDEO’s Design Thinking Framework
21
MAIN ORIGINATORS OF THE THEORY
Tim Brown/David Kelley (CEO of IDEO/company founder of IDEO) and Roger Martin
Other important authors or works:
3 I Model and HCD Model (Tim Brown/IDEO)
Service Design Model (Stickdorn & Schneider)
Double Diamond model (British Design Council Institute)
Design Thinking model (Hasso-Plattner-Institute)
OVERVIEW
Design Thinking!is a problem-solving approach that can transform the way organizations develop
products, services, and processes. The benefit of Design Thinking is that it brings together what is
desirable from a human point of view to what is feasible from an economic and technological per-
spective. People who are not trained as designers are given the tools to address a vast range of chal-
lenges. As defined by Tim Brown, executive Chair of IDEO, the design company which created the
Design Thinking Framework: “ Design Thinking is a human-centered approach to innovation that
draws from the designer’s toolkit to integrate the needs of people, the possibilities of technology,
and the requirement for business success.”7
Rather than convincing people to buy into what businesses are selling, Design Thinking focuses on
the actual needs of people (known as “end users”). It revolves around field research and the ex-
change of ideas that often leads to unexpected results. It can weave together the elements of human
psychology, sociology, demographics, environmental factors, and anthropology to generate novel
solutions to some of the perplexing problems in business.
Another major feature of Design Thinking is the concept of rapid prototyping rather than thinking
about feasibility. By creating and abandoning multiple prototypes (which can range from a sketch,
symbol, or text, to a complex 3-dimensional model), idea generation is compounded and bound-
aries become less and less limiting.1
Background
In comparison to the rigorous scientific method of investigation, Design Thinking is a relatively new
methodology. The practice originated as a response to the question of what design had to contribute
to the modern world. The first person to mention design thinking as a way of thinking is the scholar
and cognitive scientist Herbert A. Simon in his 1969 book titled, The Science of the Artificial.6 He con-
tinued to contribute many ideas throughout the ’70s which are now regarded as principles of Design
Thinking.4
Tim Brown and David Kelley are among the founders and originators of IDEO Design Thinking.
Brown implemented three core steps for his method: Inspiration, Ideation, and Implementation. This
3 I’s model was developed in the context of social innovation. The first Design Thinking space, Inspi-
ration, involves identifying the idea or opportunity, creating a framework for the design team, and
observing the habits and behavior of the target group in their environment. Then, Ideation creates a
space for an interdisciplinary team to work together and share their insights into what was observed
in order to provide solutions or design new models. Complex ideas or difficult problems can be bro-
ken down into less complicated concepts by utilizing visual representations or concept maps. Finally
comes Implementation which is a Design Thinking space that is heavily focused on creating a Proto-
type of the action plan. Through prototyping, newly developed ideas are transformed to a final prod-
uct delivered to its target audience. Contrary to one might think, innovation through the 3I’s phases
does not need to be linear. The process can start or end at any phase as deemed necessary by the de-
sign team and until the final product is created.2 According to Brown, there are some important char-
acteristics that the design thinker needs to have in order to be successful in his model. They include
the following:
1. Empathy
2. Experimentalism
3. Optimism
4. Collaboration and teamwork
5. Ability to balance feasibility, viability, and desirability
Some of the success factors that are necessary for Brown’s model include:
•”Fail earlier to succeed sooner” requires simple prototypes to receive early feedback;
•Focus on human needs, behavior, and empathy innovation through the 3I’s phases does not need to
be linear. The process can start or end at any phase as deemed necessary by the design team and un-
til the final product is created.2
22
Modern takes on this Theory
As an example of how design thinking found its way to Medicine, students in a two-day course of-
fered by the Hasso Plattner Institute of Design at Stanford looked for ways to improve the patient
experience in the Emergency Department. Participants in the course were given roles as patients and
family members to get a sense of what it actually feels like to be in the often chaotic and highly
stressful environment of the Emergency Department. Before conducting the exercise, the course par-
ticipants were asked to interview patients and family members who were being seen about their ex-
periences with medical care. By connecting and empathizing with patients and their family mem-
bers, students were then able to feel what was like to be in their shoes. The first day produced an
abundance of material to guide the class’ second day of prototyping. It became evident that certain
themes were occurring frequently. Patients and their loved ones wanted a regular flow of informa-
tion to help them understand what was going on with their care. They also wanted to know that
their providers were communicating with one another. By ensuring clear communication and regular
updates, patients would feel relieved which in return reduced the anxiety and fear experienced by
their loved ones.
The participants concluded the class by presenting their research results and ideas to the administra-
tive staff who decided to implement them to their ED design.3Design thinking has also been used in
curricular design to expand data utilized in the course evaluation stage, as well as through the idea
of prototyping.5
Other Examples of Where this Theory Might Apply
Design thinking serves as a unique opportunity to pair students’ developing critical-thinking skills
with a creative outlet. This level of brainstorming works well in earlier levels of training, before
learners’ creativity is limited by “rules” or tradition. Students can create needs assessments within
their own class regarding aspects of the curriculum they feel need to be better addressed. They then
have the opportunity to brainstorm with their colleagues and other schools (Public Health, Pharma-
cy, Nursing, Dietetics, Design, Engineering, etc.) and develop prototypes in a “flipped classroom”
format.
Design thinking is also well-suited for problem-solving gaps in the curriculum. As an example, med-
ical education is currently limited on its ability to encourage empathy in students, but advances in
virtual reality (medical professionals working with engineers and humanities expertise) have al-
lowed for students to simulate brief moments of time in their patients’ days. Design thinking can
also help address resource limitations by pooling supplies across multiple departments and develop-
ing more simplistic products or models to meet educational needs (ex. designing an intravenous
pacer task trainer). Products created through design thinking can help adjust inconsistencies in train-
23
ing experiences. Collaboration with other schools of thought can enrich learning experiences, improve
networking, and instill a deeper appreciation of other people’s employment and passions.
Limitations of this Theory
While design thinking can be praised for its innovative approach and interprofessional culture, it is not
without its limitations. For design thinking to function at its best, teams need to have adequate time to
devote to brainstorming, and project design needs to take place in an environment that encourages and
values creativity. Participants should understand that design thinking requires those who engage within
it to have a failure-positive mentality; that is, not only is failure acceptable but rather it is expected, since
innovators often fail so that they can learn about the weakness in a prototype and improve. This theory
is most valuable when applied by a team with a diverse background, so projects taking this approach
should be reaching out to additional collaborators from other schools of thought (engineering, design,
etc.). The team should be open, interested, and actively engaged. It may be challenging to network with
other departments and will take time to build working relationships with these new members of the
team. Additionally, design thinking is still relatively new in its application to the medical field. There is
a paucity of research on its efficacy in resolving obstacles in healthcare. As more schools adopt design
thinking theory in their curriculum, we will have a better idea of its best role in our learners’ education.
Returning to the case...
Dr. Pneumo understands that collaboration across professions is important in design theory, so she reaches out to
neighboring engineering, design, and social work schools. She also networks with the hospital’s psychiatry depart-
ment and the local mental health clinic to interview patients with schizophrenia, their caretakers and family mem-
bers, and the hospital’s own healthcare providers. By doing this groundwork, Dr. Pneumo is able to get a better un-
derstanding of the obstacles these patients encounter daily, in their own words. Dr. Pneumo shares these inter-
views with the engineers and designers who have joined her team.
Together, they design a prototype for a virtual reality headset that mimics some of the consistent auditory and vis-
ual hallucinations the patients are experiencing in their daily lives. She shares this prototype with the patients and
their families to assess its realism and incorporates their feedback into the scenario and software designs with her
team.Once all team members are satisfied with the prototype, Dr. Pneumo introduces the hallucination glasses into
a pilot curriculum for students. The glasses are well-received, with many students comments on how poorly they
understood what their patients were going through.
Over time, enough data is collected to support making the glasses a permanent fixture of the clerkship curriculum.
On a recent shift, Dr. Pneumo overhears a new rotator in the department venting about a “crazy” patient. “I tried
asking him the same question, like, five times, and all he would do was stare at the wall right behind me! Clearly he
doesn’t want my help that badly if he can’t take the time to talk to me.” Before Dr. Pneumo can intervene, another
learner pulls the new rotator aside. “Hold on,” he says, “I know that you’re frustrated and just want to help. I bet
your patient is going through a lot right now, let’s see how we can work together to get him the care he needs.”
24
References
1. Efeoglu A, Møller C, Sérié M, Boer H. Design thinking: characteristics and promises. In: Pro-
ceedings of 14th International CINet Conference on Business Development and Co-Creation. ;
2013:241–256.
2. Tschimmel K. Design Thinking as an effective Toolkit for Innovation. In: ISPIM Conference
Proceedings. The International Society for Professional Innovation Management (ISPIM);
2012:1.
3. Wykes S. Design thinking as a way to improve patient experience. News Center. Accessed
August 23, 2020. http://med.stanford.edu/news/all-news/2016/06/design-thinking-as-a-way-
to-improve-patient-experience.html
4. Plattner, Meinel, Leiffer eds. Design Thinking: Understand - Improve - Apply. Springer-Verlag
Berlin Heidleberg, 2011.
5. Gottlieb M, Wagner E, Wagner A, Chan T. Applying Design Thinking Principles to Curricular
Design in Medical Education. AEM Education and Training 2017; 1: 21– 26
6. Simon HA. The Sciences of the Artificial. Çambridge, MA: MIT Press, 1969.
7. Brown T. Change by Design: How Design Thinking Transforms Organizations and Inspires Innova-
tion Harper Business, 2009.
25
26
ANNOTATED BIBLIOGRAPHY
1. McLaughlin J, Wolcott M, Hubbard D, Umstead K, Rider T. A qualitative review of the design
thinking framework in health professions education. BMC Med Educ. 2019;19(1).
This reference serves as a qualitative review of design thinking in health profession education starting
in 2009 (the presumed advent of DT in the health profession). The fifteen articles selected are a blend of
peer-reviewed research and commentary on the education framework that explore the possible role of
design thinking in problem-solving, curriculum development, and quality improvement for patient
care. The authors suggest that design theory is a unique approach to uncover novel solutions to current
problems in both health education and the act of health care, while acknowledging that this frame-
work’s use in medical education is contemporary with limited data.
2. Madsbjerg C, Rasmussen MB. An anthropologist walks into a bar. Harvard Business Review. 2014
Mar 1;92(3):80-90.
This paper provides an overview of the design thinking process from a business angle and why
various companies (e,g. Lego) have found it useful to engage in observations of their end-users. It
provides an overview of the Sensemaking process (1. Reframe the Problem; 2. Collect the Data; 3. Look
for Patterns; 4. Create the Key Insights; 5. Build the Business Impact).
3. Panke S. Design thinking in education: Perspectives, opportunities and challenges. Open
Education Studies. 2019 Jan 1;1(1):281-306. doi: 10.1515/edu-2019-0022
An excellent recent review of the design thinking literature within education. Provides linkages to
empirical studies across all of education.
Practical Papers in Medical Education
4. Gottlieb M, Wagner E, Wagner A, Chan T. Applying design thinking principles to curricular
development in medical education. AEM education and training. 2017 Jan;1(1):21-6. doi: 10.1002/
aet2.10003
This paper provides some worked examples specific to a particular field (emergency medicine).
Highlighting how design thinking may enhance curricular design.
5. Thakur A, Soklaridis S, Crawford A, Mulsant B, Sockalingam S. Using rapid design thinking to
overcome COVID-19 challenges in medical education. Academic Medicine. 2021 Jan;96(1);56-61. doi:
10.1097/ACM.0000000000003718
A more recent article that provides a worked example for how a group used rapid design thinking to
overcome educational challenges during the COVID-19 pandemic.
6. Chorley A, Azzam K, Chan TM. Redesigning continuing professional development: Harnessing
design thinking to go from needs assessment to mandate. Perspectives on Medical Education.
Online first. 2020 Aug 12:1-6. doi: 10.1007/s40037-020-00604-1
Another worked example of how a design thinking engagement helped a group redesign their
continuing professional development needs.
A Case
Kate is the program director for an emergency medicine residency and is scheduling the upcoming end-of-year re-
views. She has received verbal and written feedback that John, a new intern, has been continuing to demonstrate a
below-average knowledge base, and has been having a challenging time balancing an appropriate patient load as
well as developing appropriate treatment plans on shift.
Early on during the intern year, John struggled to keep up with other members of his class, and Kate had met with
him for a mid-year evaluation. She discussed some of the comments she had received about his performance, and he
seemed to react negatively toward the feedback. Kate tried to provide encouragement but was concerned that John
has not made any changes to help him progress. This frustrates Kate as she took extra time and effort to help John
but feels as though she wasn't able to get through to him.
Before the first feedback session, John felt he was on track for his level of training and was very surprised to receive
negative feedback from the faculty. He felt defensive throughout the whole discussion and left the meeting frustrat-
ed, thinking that the faculty were unreasonable and were too judgemental.
Kate had hoped that the session would inspire him to make changes but is worried that John will not progress ade-
quately. She would like to have a more constructive end-of-year evaluation session with John to help him meet the
potential she sees in him.
27
CHAPTER 4
Authors: Sean Dyer, MD; Geoffrey Comp, DO
Editor: Michael Gottlieb, MD; Teresa Chan, MD, MHPE
The R2C2 Feedback Model
Background
Feedback is essential to a learner’s growth and continues to be an important area of study for medical
educators.3,4 Effective feedback can be used to help a new learner acquire or solidify new concepts. It has
been shown to improve technical hands-on skills as well as patient communication, leadership, team-
work, and physician well-being.1 While the importance of feedback is widely understood, high-quality,
evidence-based recommendations for feedback are lacking.4
The authors of the R2C2 Feedback Model sought to create an evidence-based and theory-informed
model for facilitating performance feedback.2 The authors sought to address the existing challenges with
feedback receptivity and using feedback to inform one’s self-assessment and performance
improvement.5 Using theoretical frameworks and evidence from the literature, the team identified the
following three components2,6:
1. Focusing on enhancing individual self-awareness and engaging with the learner through a hu-
manist and person-centred approach;
2. Using an informed self-assessment approach that allows a learner to utilize external feedback to
help generate an appraisal of their own performance; and
3. exploring the science of behavior change to enhance the incorporation of feedback.
28
MAIN ORIGINATORS OF THE THEORY
Joan Sargeant, PhD
Karen Mann, PhD
OVERVIEW
The R2C2 Feedback Model is a structured, four-phase method for providing feedback to learners. The
facilitator guides a collaborative discussion through the four steps of building Relationships, exploring
Reactions, exploring the Content of the feedback, and Coaching for change, thereby enhancing
feedback acceptance and use.1,2 In the first phase, the facilitator attempts to build the relationship and
establish trust through empathy and establishing credibility of the process. The second phase involves
exploring the learner's reaction to the feedback through open-ended questions and reflective listening
with the goal of providing a safe environment. In the third phase, the content of the feedback is
examined. The learner is encouraged to clarify any questions about the feedback and identify
strengths, weaknesses, and opportunities for improvement. Finally, in the fourth phase, the facilitator
provides coaching for performance change through mutual identification of actionable goals as well as
specific strategies to attain these objectives. [2]Each of these four steps guides the feedback
conversation and utilizes specific open-ended questions to promote self-reflection and self-direction by
the learner.3
Through these lenses, the group derived a structured method to “facilitate formal feedback and
coaching conversations, enable collaborative discussions between supervisors and residents, and es-
tablish a safe environment through a series of open-ended questions that emphasize reflection and
continual improvement.”1
The authors tested the method and provided both objective and subjective supporting evidence of
the benefits of successful implementation of the system. The group performed two studies across
multiple sites and programs in graduate medical education, demonstrating that the R2C2 model
was effective in engaging residents in a reflective and meaningful goal-oriented interaction.3,7 The
authors also developed and published an online tool kit comprised of templated handouts and
video resources for implementation of the program.5
The authors surveyed educators and learners after implementation of an R2C2 session and identi-
fied three features that were most valuable in successfully providing and accepting feedback. First,
the use of open-ended questions was reported to promote a respectful teacher-learner relationship,
which was paramount in the success of the session. Second, the discussion was more effective when
the content was oriented toward coaching and the learners use of assessment data. Finally, the goal
of fostering teacher-learner collaboration assisted in the development of the learner’s goals and de-
termination of areas for growth.3
Modern Takes on this Theory
Many of the techniques that Drs. Mann & Sergeant had introduced to the world via the R2C2 model
overlap extensively with the key features of a number of findings in simulation debriefing. More re-
cently, Dr. Sargeant has collaborated with a number of collaborators from the feedback and simula-
tion debriefing world to attempt to coalesce two bodies of literature that have historically been quite
disparate. This group have recent published a paper rebranding all of these post-learning encoun-
ters as Learning Conversations.8
Other Examples of Where this Theory Might Apply
A modified version of the R2C2 Feedback Model appropriate for shorter interactions has been de-
scribed.1 This allows for the teacher to still use the four stages as described above but in a shorter
time period without losing the benefits provided by the model. This is a useful variation for teachers
to ensure their feedback is given in the moment, instead of waiting until a mid- or end-of-year eval-
uation. While it was initially developed to guide a formal feedback session, a similar model can be
used to help deliver feedback and provide coaching opportunities in real time. For example, an
Emergency Medicine attending physician could use the R2C2 model at the end of the learner’s shift,
rather than waiting until the end of the rotation.
29
Limitations of this Theory
The R2C2 Feedback Model has several limitations. One of the most commonly cited limitations in the
initial articles was the time commitment. It requires a 30-60 minute meeting as well as time for the
instructor to learn the technique and time for the learner to review their feedback ahead of time.
These issues are partially addressed by the ‘in-the-moment’ modification discussed above. Addition-
ally, in order to achieve meaningful feedback, the learner must be able to self-reflect on their perfor-
mance and to discuss their reactions to the feedback. For learners who have difficulty with this step,
it might limit the quality of feedback and coaching acquired with this model
Returning to the case...
Kate was determined to lead a constructive feedback session with John and used the R2C2 Feedback Model to
structure the discussion. She started the meeting by setting the stage and building the relationship by explain-
ing the purpose of the feedback session as well as the review process. She asked if he had any other questions,
and she was surprised to hear that John was very nervous about the review and didn’t know what he was sup-
posed to learn from the process. John felt much more involved as Kate explained the review process as well as
how the feedback was collected.
Kate then asked John to review the on-shift feedback with her. She asked him about his initial reactions as well
as if there was anything that was particularly surprising. John was initially visibly hurt and irritated when
reading the comments. However, Kate was able to listen and affirm his reactions to the feedback. Ultimately,
she discovered he had been wanting to improve some of the weaknesses that were being uncovered but didn’t
know how to address them.
By asking if there were any issues with the content of the feedback forms, Kate was able to help John identify
that charting on shift was a specific area he wanted to improve. John felt that he was listened to and started to
change his opinion of the conversation from a negative, accusatory interpretation to one of encouragement and
constructivity.
Finally, Kate was able to help coach John by helping him identify one of his senior residents that he looks up to
as a person to discuss charting skills. They also had an excellent discussion about some of the barriers John felt
he needed to overcome in order to make the changes in his workflow. Both Kate and John left the meeting feeling
encouraged by the discussion and optimistic for a positive change in John’s performance.
References
1. Lockyer J, Armson H, Könings KD, et al. In-the-Moment Feedback and Coaching: Improving
R2C2 for a New Context. J Grad Med Educ. 2020;12(1):27-35.
2. Sargeant J, Lockyer J, Mann K, et al. Facilitated Reflective Performance Feedback: Developing an
Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content,
and Coaches for Performance Change (R2C2). Acad Med. 2015;90(12):1698-1706.
3. Sargeant J, Lockyer JM, Mann K, et al. The R2C2 Model in Residency Education: How Does It Fos-
ter Coaching and Promote Feedback Use?. Acad Med. 2018;93(7):1055-1063.
30
31
ANNOTATED BIBLIOGRAPHY
1. Sargeant J, Lockyer J, Mann K, et al. Facilitated Reflective Performance Feedback: Developing
an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Con-
tent, and Coaches for Performance Change (R2C2). Acad Med. 2015;90(12):1698-1706.2
This is the landmark paper from the initial authors that provides the background research, assess-
ment of previous work in the field, and description of the derivation of the R2C2 technique. The ar-
ticle contains an extended description of the methods with specific insight into each of the four
components of the theory and examples of how they might be addressed.
2. Sargeant J, Lockyer JM, Mann K, et al. The R2C2 Model in Residency Education: How Does It
Foster Coaching and Promote Feedback Use?. Acad Med. 2018;93(7):1055-1063.3
The authors build on their original framework by applying the R2C2 model to a larger population
with a variety of learners and teachers. They discuss factors that influenced the quality of the R2C2
sessions including the relationship between the teacher and learner as well as the characteristics of
each of the participants. The importance of a Learning Change Plan is emphasized in this article and
suggests this might be the most novel and useful part of the theory for the learner as it provides
them with a plan to move forward and take action on the feedback they received.
3. Sargeant J, Mann K, Manos S, et al. R2C2 in Action: Testing an Evidence-Based Model to Facil-
itate Feedback and Coaching in Residency. J Grad Med Educ. 2017;9(2):165-170.7
In this paper, the authors describe an approach to integrate the feedback and coaching method into
mid- and end-of-year evaluations for residents. Many residencies already have this format of bi-an-
nual or annual feedback already in place; therefore, this is a very practical example of how to inte-
grate the R2C2 into practice with little additional structure. It provides a good framework for su-
pervisors to provide feedback to the learners and incorporate coaching. It was found to be especial-
ly helpful in providing feedback and suggestions for improvement to students who were already
excelling, as this can be more complicated for supervisors than the student requiring more attention.
4. Lockyer J, Armson H, Könings KD, et al. In-the-Moment Feedback and Coaching: Improving
R2C2 for a New Context. J Grad Med Educ. 2020;12(1):27-35.1
Previously, the R2C2 model was used primarily for end-of-rotation feedback sessions that encom-
pass multiple types and sources of feedback. This paper discussed how to adapt the R2C2 model to
use for individual, shorter encounters, such as at the end of a clinical.
4. Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in
Medical Education: What Is Known? A Scoping Review. Acad Med. 2017;92(9):1346-1354.
5. Sargeant J, Armson H, Driessen E, et al., Evidence-Informed Facilitated Feedback: The R2C2
Feedback Model. MedEdPORTAL. 2016. DOI: 10.15766/mep_2374-8265.10387
6. Armson H, Lockyer JM, Zetkulic M, Könings KD, Sargeant J. Identifying coaching skills to im-
prove feedback use in postgraduate medical education. Med Educ. 2019;53(5):477-493.
7. Sargeant J, Mann K, Manos S, et al. R2C2 in Action: Testing an Evidence-Based Model to Facili-
tate Feedback and Coaching in Residency. J Grad Med Educ. 2017;9(2):165-170.
8. Tavares W, Eppich W, Cheng A, Miller S, Teunissen PW, Watling CJ, Sargeant J. Learning conver-
sations: an analysis of the theoretical roots and their manifestations of feedback and debriefing in
medical education. Academic Medicine. 2020 Jul 1;95(7):1020-5.
A Case
As she pre-rounding for Trauma Surgery rounds, medical student Jane Adams felt she was as prepared as she could
be. She had arrived early to interview their patient, Frank, and had been through all the labs twice. She again
ruffled through her notes as the other student on the service, Jagdeep Sahotra.
“You’re late again,” she sighed.
“I know, I know…” replied Jagdeep as he quickly jotted down the latest vital signs. He had missed his chance to
examine Frank that morning. Dr. Fox, the Attending Surgeon, had already arrived so they quickly rushed off after
him. As they arrived at Frank’s room, Jane started with the presentation and John added in the additional vital
signs and stated that Frank appeared in a better mood this morning.
As they walked into the room, Dr. Fox again introduced the students.
“Good morning, you remember student doctor Jane and student doctor Sahotra.”
“Yes,” Frank stated, “I remember them! It’s good to see you again Dr. Sahortra and Jane.”
Jane watched Dr. Fox, and hoped he would correct Frank but instead he just nodded along. John quickly responded
to the patient with, “It's good to see you again. I’m happy to see you doing so well.”
As they walked out of the room, Frank called out to ask for juice. Dr. Fox turned to Jane and asked her to go down
the hall and grab the juice for him. She rushed off so that she could meet the needs of her patient, but when she ar-
rived back on rounds, Dr. Fox had just finished discussing the plan for Frank that day. Dr. Fox commented on the
excellent rapport Jagdeep had with Frank and announced that John would be the student to join him in the operat-
ing room that afternoon. Jane wondered what she could do about this disparaging situation.
32
CHAPTER 5
Authors: Lauren Evans, MD; Dolly Yadav, MD
Editor: Sreeja Natesan, MD; Teresa Chan, MD, MHPE
Feminist Theory
Background
In 1848, a group gathered in Seneca Falls, New York seeking equal rights for women, including suffrage,
education, and property rights, but later focused mainly on the right to vote. This first-wave feminism
ultimately led to the 19th amendment being passed in the United States in 1920. The movement contin-
ued in other countries, and Saudi Arabia became the last country to allow women to vote in national
elections (2015). After women's suffrage was passed, there was a decline in the movement in the United
States. In the 1960’s, a second-wave feminism was born and since that time feminism has been a con-
stant, evolving theory. Second-wave feminism focused primarily on workplace rights and reproductive
rights. They sought equal pay, equal job opportunities, and improved childcare options. Third-wave
feminism challenged gender identity and the rights of underrepresented females, and fourth-wave fem-
inism has focused on sexual harassment.
Sharma2 identifies 11 different feminist theories that are present in the medical literature, including ex-
amples and critiques. These broad theories show the diversity of the topic and the avenues for future re-
search. We have adapted the table by Sharma below for your reference.
33
MAIN ORIGINATORS OF THE THEORY
Sandra Lee Bartky, Annette Claire Baier, Simone de Beauvoir, Ferdinand Bebel, Grace Lee Boggs,
Judith Butler, Hélène Cixous, Voltaire Cleyre, Juana Inés de la Cruz, Patricial Hill Collins, Mary
Daly, Angela Davis, Emma Goldman, Sally Haslanger, bell hooks, Catharine MacKinnon, Amina
Mama, Louise Michel, John Stuart Mill, Kate Millett, Martha Craven Nussbaum, Estelle Pankhurst,
Carole Pateman, Val Plumwood, Gayle Rubin, Nawal El Saadawi, Gayatri Chakravorty Spivak,
Suzanne Voilquin, Mary Wollstonecraft, Iris Young, Clara Zetkin.
OVERVIEW
Feminism has been defined by feminist scholar and author, bell hooks, as “a movement to end sexism,
sexist exploitation and oppression.” While there exists no singular feminist theory, Sharma describes
“a family of critical theories and approaches that enable us to understand complexity.” Sharma also
wrote a scoping review examining feminist theory as it relates to medical education and medical
education research and found four overarching topics that exist in the Feminist theory literature:
●Assessment of what is taught in medical curricula: Addressing the need for more education in
women’s health and gender sensitivity.
●Female experiences in medical training: Perspectives of female trainees, including challenges
faced.
●Pedagogical approaches to medical education: Scrutinizing hidden curriculum and assumptions.
●Methodologies and inquiries in medical education research: What questions are asked and is
there action based on these questions.
34
Table: A summary of feminist approaches that are commonly encountered.
Please note that this table is not exhaustive and is only meant to show the breadth of approaches within feminist theory.
Principles
Examples in Health Profes-
sions Education
Problems or Critiques with this ap-
proach
Liberal Feminism
All genders are fundamentally equal;
social conditions create and dictate dif-
ferences and inequities; political and
structural changes are required to close
the gap.
Implementing quotas and other
recruitment policies that increase
the number of women in leader-
ship positions.
Has been critiqued for the lack of intersec-
tional awareness of other oppressive factors
(e.g. race, class, language, sexual orienta-
tion, etc..).
Cultural Feminism
Women and men are fundamentally
different and that there are certain at-
tributes within women (e.g. being more
relational or empathetic) that come
more naturally to them.
Examining the caring nature of
more “feminine” specialties with-
in medicine.
Rather reductionistic at times. Notion of
male vs. female attributes, values, and set
points are problematic for many. Denies a
spectrum of genders.
Queer Feminism
Core to this movement are the concept
that sex and gender are socially con-
structed.
Work that examines gendered
experiences between men and
women physicians with other
staff within the operating room
setting.
Focuses on discourse and therefore may
preclude examination of social structures
that are at play (e.g. race, class, sexual ori-
entation, etc..)
Radical Feminism
Identifies the patriarchy as the main
source of oppression and gender as a
tool of these individuals to oppress
women. Suggests that radical (and not
incremental) change is required.
Enacting legal changes to legisla-
tion around women’s reproduc-
tive rights.
Many critics feel that radical change is un-
likely to occur in most jurisdictions and
may be a fantasy.
Anti-racist
Feminism
Race is an oppressive construct.
Creating a curriculum that exam-
ines the intersectionality of gen-
der AND race in the clinical
learning environment.
Leans heavily towards seeing intersection-
ality as a probably solution. May not exam-
ine other sources of structural or cultural
oppression.
Socialist
Feminism
Emphasizes economic oppression.
Women’s oppression is part of a large
structural inequity that is driven by
class and economics.
Creating new policies for encour-
aging all genders to engage in
parental leave.
Often misses out on other sources of op-
pression (e.g. race, language, sexual orienta-
tion, etc..)
Postmodern
Femininism
Language and social discourse create
our understanding of women and their
identity.
Examining medical literature or
policy documents for evidence of
gender bias.
Focuses largely on language and does not
often create new structures and enable
change.
Indigenous
Feminism
Focuses on how decolonisation and in-
digenous sovereignty may intersect
with feminism.
Indigenous cultural safety train-
ing for clinicians and trainees.
Often very North American-centric, al-
though Australia and New Zealand are of-
ten thought of as leaders in this space as
well.
Marxist Feminism
Sees capitalism as primary source of
oppression, leading to a devaluing or
undervaluing of women’s labour.
Determining differences in
women and men’s clinical rev-
enues and academic contribu-
tions to see if women are penal-
ized for increased caregiving and
household labour responsibilities.
Does not usually account for other intersec-
tional sources of oppression (e.e. race, lan-
guage, sexual orientation).
Postcolonial
Feminism
Asks us to examine via a postcolonial
lens whether white women’s experi-
ences and values are being generalised
inappropriately.
Examination of a medical school
application system to examine
how non-White women experi-
ence this process.
Colonialist and imperialist practices are still
pervasive in the world, so perhaps the
“post” in postcolonialism is inappropriate.
Modern takes on this Theory
Organizations, such as FemInEM (feminism.org), have created online communities of practice directed
at gender equity and empowering all physicians. They aim to “address gender disparities in a posi-
tive way.” This community has open access to resources for gender studies in medicine directed at
both personal and group development. They also have in-person events available for further net-
working and education. FemInEM also supports research into gender equity in medicine. SheMD is
another example of an organization that uses the online social media platform of Twitter to educate
on topics of gender equity, workplace disparities, and more. National organizations such as ACEP,
SAEM, and others have created Women In Medicine committees to also help advocate for policy
changes, increase education on gender equity issues, and allow networking and creation of a com-
munity for women in medicine.
Other Examples of Where this Theory Might Apply
In the classroom, Feminist theory has recognized the “one-sex body” present in the pre-clinical cur-
riculum. Studies have found that anatomy textbooks have more anatomic illustrations of male fig-
ures than females as the “norm.” The concerns that arise are that medical students are less likely to
fully recognize the normal female anatomy or the differences between the sexes. In Emergency Med-
icine, we can see an example of this with the teaching of thoracostomy tubes. One of the most com-
monly used books for procedures, Roberts and Hedges’, uses a male figure to show anatomy and
states “the fifth intercostal space is approximately at the level of the nipple,” but “the position of the
female breast mass leads to variance” with no further information provided. The concern is that stu-
dents who use these resources will be less prepared to properly care for a female patient compared to
their male counterpart.
Feminist theory has also looked broadly at the experience of females in the clinical setting. There has
been literature that focuses on the different experiences of female and male medical students, resi-
dents, and faculty. This research has identified significant challenges including sexual harassment
and hostile work environment. There has also been significant research into the reduction of female
career advancement and the lower numbers of female editors in medical journals.
Limitations of this Theory
Sharma2 notes that there appears to be a deficit in the number of publications referencing feminist
theory in medical education. She notes that this is possibly related to a publication bias. There has
been literature that identifies a male dominance in the editorial boards of prominent medical jour-
nals,9 with up to only 21% of editorial board members found to be female. There has also been re-
search into the underrepresentation of female authorships in both medical, and general sciences, lit-
erature.
35
Returning to the case...
Jane focused on the morning’s events wondering what she could have done differently. She knew that she had
been better prepared for the day than John, but felt frustrated that she had still missed out on the afternoon
surgeries. She discussed the problem with her roommate and he suggested that she speak to Jagdeep about it
tomorrow.
“Maybe he didn’t realize what was happening?” he asked.
The next morning when Jagdeep arrived, Jane brought up the topic. Initially, Jagdeep felt frustrated because he
knew he deserved to see the surgeries. She reminded him that he had been late that day and hadn’t even exam-
ined Frank.
She then asked him “Did you notice how Frank called you Dr. Smith and then referred to me as Jane and Dr.
Fox just ignored it?”
She reminded him that Dr. Fox had sent her to go get juice instead of hearing about the plan for her patient.
The more examples of the sexism that had occurred, the more Jagdeep realized the struggles that Jane was fac-
ing.
“I didn’t realize what was happening or I would have said something!” Jagdeep said.
Jane believed him, but wondered what could be done to prevent it from happening again. She had heard about
some medical schools that were incorporating gender awareness into their curriculum and thought maybe her
school could do the same. Jagdeep agreed that it was needed and asked to be a part of this new project. They set
off that afternoon to find a mentor for their new curriculum and to figure out ways to disseminate this to the
faculty and staff as well.
References
1. hooks, bell, 1952-.!Feminism Is for Everybody : Passionate Politics.!Cambridge, MA:
South End Press, 2000.
2. Sharma M. Applying feminist theory to medical education.!Lancet.
2019;393(10171):570-578. doi:10.1016/S0140-6736(18)32595-9
3. Burkett E, Brunell L. feminism | Definition, History, & Examples. Encyclopedia
Britannica.!https://www.britannica.com/topic/feminism.!Published 2020.
4. FemInEM. FemInEM.!https://feminem.org/about/. Published 2020.
5. Mendelsohn KD, Nieman LZ, Isaacs K, Lee S, Levison SP. Sex and gender bias in
anatomy and physical diagnosis text illustrations.!JAMA. 1994;272(16):1267-1270.
doi:10.1001/jama.1994.03520160051042
36
6. Thomsen, and Jerris R.!Hedges. Roberts and Hedges’ Clinical Procedures in Emergency
Medicine., 7th!ed. Elsevier; 2014.
7. Wear D, Aultman JM, Borges NJ. Retheorizing sexual harassment in medical education:
women students’ perceptions at five U.S. medical schools.!Teach Learn Med.
2007;19(1):20-29. doi:10.1080/10401330709336619
8. Raj A, Kumra T, Darmstadt GL, Freund KM. Achieving Gender and Social Equality:
More Than Gender Parity Is Needed.!Acad Med. 2019;94(11):1658-1664. doi:10.1097/
ACM.0000000000002877
9. Jagsi R, Tarbell NJ, Henault LE, Chang Y, Hylek EM. The representation of women on the
editorial boards of major medical journals: a 35-year perspective.!Arch Intern Med.
2008;168(5):544-548. doi:10.1001/archinte.168.5.544
10.Babaria P, Bernheim S, Nunez-Smith M. Gender and the pre-clinical experiences of
female medical students: a taxonomy.!Med Educ. 2011;45(3):249-260. doi:10.1111/
j.1365-2923.2010.03856.x
11.Cheng LF, Yang HC. Learning about gender on campus: an analysis of the hidden
curriculum for medical students.!Med Educ.!2015;49(3):321-331. doi:10.1111/medu.12628
12.MacLeod A, Frank B.!Feminist pedagogy and medical education: why not now?!Med
Educ.!2013;47(1):11-14. doi:10.1111/medu.12095
13.Silver JK, Poorman JA, Reilly JM, Spector ND, Goldstein R, Zafonte RD. Assessment of
Women Physicians Among Authors of Perspective-Type Articles Published in High-
Impact Pediatric Journals.!JAMA Netw Open. 2018;1(3):e180802. Published 2018 Jul 6.
doi:10.1001/jamanetworkopen.2018.0802
14.Hsiehchen D, Hsieh A, Espinoza M. Prevalence of Female Authors in Case Reports
Published in the Medical Literature.!JAMA Netw Open. 2019;2(5):e195000. Published
2019 May 3. doi:10.1001/jamanetworkopen.2019.5000
15.Gender imbalance in science journals is still pervasive.!Nature.!2017;541(7638):435-436.
doi:10.1038/541435b
16.Bendels MHK, Müller R, Brueggmann D, Groneberg DA. Gender disparities in high-
quality research revealed by Nature Index journals.!PLoS One.!2018;13(1):e0189136.
Published 2018 Jan 2. doi:10.1371/journal.pone.0189136
37
38
ANNOTATED BIBLIOGRAPHY
1. Sharma M. Applying feminist theory to medical education.!Lancet. 2019;393(10171):570-578.
doi:10.1016/S0140-6736(18)32595-9
Provides an excellent overview of Feminist theory and how it can be applied within medical
education.
2. Babaria P, Bernheim S, Nunez-Smith M. Gender and the pre-clinical experiences of female
medical students: a taxonomy. Med Educ. 2011;45(3):249-260. doi:10.1111/j.1365-2923.2010.03856.x
A qualitative study looking at female’s pre-clinical experiences relating to gender. The students re-
ported multiple negative experiences that left them isolated and questioning of a future in the med-
ical field.
3. Cheng LF, Yang HC. Learning about gender on campus: an analysis of the hidden curriculum
for medical students. Med Educ. 2015;49(3):321-331. doi:10.1111/medu.12628
This paper examines posts by medical students from multiple schools posted on an online commu-
nication board. Authors found biased treatment of women and overt sexual harassment present
from both students and faculty. Among the strategies suggested to promote gender sensitivity is re-
counting examples of the lived experiences of those who have been discriminated against in med-
ical curricula.
4. MacLeod A, Frank B. Feminist pedagogy and medical education: why not now? Med Educ.
2013;47(1):11-14. doi:10.1111/medu.12095
This paper examines the need for social sciences such as gender and race studies in medical curricu-
lum.
5. Mendelsohn KD, Nieman LZ, Isaacs K, Lee S, Levison SP. Sex and gender bias in anatomy and
physical diagnosis text illustrations. JAMA. 1994;272(16):1267-1270.4
This paper looks at the disproportionate number of male illustrations in anatomy textbooks used
during pre-clinical years. Thus further perpetuating the male body as the medical standard and lim-
iting medical student’s understanding of female anatomy. Also, female images were disproportion-
ately higher in the reproductive chapters versus male’s.
A Case
Ms. Smith, an 87 year old with a past medical history of untreated hypertension, called the ambulance when she
developed significant chest pain. On arrival, she informed Shannon, one of the paramedics, that the severe, tearing
pain began suddenly about one hour prior and radiated into her left arm and back. As per her medical directive,
Shannon began transporting the patient and consulted with an emergency physician, Dr. Lee, via a telemedicine
link.
During transport, the telemedicine platform had connection issues and kept cutting in and out, much to the frus-
tration of Shannon and Dr. Lee. As a result, Shannon was unable to relay much of the patient’s history or her vital
signs, so Dr. Lee asked that she just send the ECG. He planned to review it to determine appropriate triage prior to
the patient’s arrival. His review of the ECG showed ST elevation in the inferior leads (II, III, and aVF), and he in-
terpreted this as consistent with an inferior ST-elevation myocardial infarction. The concerned emergency physi-
cian informed the paramedics to bypass the emergency department and transport her directly to the cardiac
catheterization suite for primary coronary intervention. He requested that the paramedics give aspirin and sublin-
gual nitroglycerin. As Shannon started to express her concern about the patient’s atypical sounding chest pain, Dr.
Lee was called overhead to attend to another sick patient. He apologized and ended the telemedicine call.
On arrival at the cardiac catheterization suite, the patient had received the requested medications. The patient was
now short of breath and hypotensive. As the paramedics handed over the patient to the interventional cardiology
team, Dr. Sam, the cardiologist, performed a bedside echocardiogram. The bedside echo demonstrated hypokinesis of
the inferior wall with moderate aortic regurgitation and a large pericardial effusion. Dr. Sam raised the concern for
an aortic dissection, which is what Shannon had been concerned about all along.
Shannon and her partner transported the patient down to the emergency department while Dr. Sam called for an
emergent cardiac surgery consult. As the paramedics bring the patient into the emergency department, Shannon
hears a familiar voice; standing before her is the now shocked emergency physician, Dr. Lee.
39
CHAPTER 6
Authors: Fawziah Alsalmi MD; Lorne Costello MD, MSc; Kristine Prince DNP, APRN;
Editor: Sara M. Krzyzaniak, MD
Sociomaterialism
MAIN ORIGINATORS OF THE THEORY
Wanda Orlikowski, Susan Scott
Other important authors or works:
Bruno Latour: actor-network theory
Karen Barad: agential realism Paul M. Leonardi: imbrications
Thomas Martine and Francois Cooren: materiality and relationality
OVERVIEW
The term “social”, defined as “relating to society or its organization,” dates back to the 17th century and
is derived from the Latin word Socialis.1 “Material” is defined as “denoting or consisting of physical
objects rather than the mind or spirit” or “important; essential; relevant.”2 In the literal sense,
sociomaterialism is a noun of the blending of the terms ‘social’ and ‘material’ first postulated by Wanda
Orlikowski as a conceptual framework for the theory of sociomateriality.3 Rather than treating the social
and material environments as two different entities, Orlikowski argues that the two are intertwined
with one being no more important than the other, a concept known as as “constitutive entanglement.”3
Derived from previous work of relational theorists, it is this constitutive entanglement that blurs the
overlap of technology, work, people, and organization.
Sociomateriality consists of five central ideas identified in the literature: materiality, inseparability, rela-
tionality, performativity, and practice.4
●Materiality can differ among professions and areas of studies, but in general refers to how some-
thing is used.
●Inseparability describes the close interrelatedness of humanity (in sociality) and materiality.
●Relationality is the inseparability of humanity and materiality in that each entity depends on one
another.
●Performativity is the notion that the “boundaries between humans and technologies are enacted
in practice.”4
●Practice relates to the development of a lens to improve one’s knowledge base and
understanding.4
In its resurgence since 2007, sociomateriality has been described as an umbrella theory containing a
number of sub-theories. These sub-theories exist within the aforementioned central ideas to aid in for-
matting the framework of sociomaterialism. Additional viewpoints on this conceptual framework in-
clude agential realism by Barad, imbrications by Leonardi, and materiality and relationality by Martine
and Cooren. Barad’s agential realism states that there is no absolute distinction between social or mater-
ial and that the concept is purely sociomaterial as one singular concept.7 Leonardi’s imbrications, or crit-
ical realism, states that social and material are separate and only “imbricates,” or overlaps, as people
create a link between the two, creating sociomaterialism.7 Martine and Cooren’s materiality and rela-
tionality were developed to help clarify the confusion created by constitutive entanglement’s language,
suggesting that the two concepts can be singular or joint depending on the situation in which the con-
cept(s) is/are needed.6
Background
The core tenant of sociomateriality is the effect technology has on human interaction, personal and
professional lives, and sociality. This framework concurrently describes effects of people on the de-
sign of, use of, and dependence on technology in the modern world. Commonly cited examples in
the literature include internet search engines and smartphones. Sociomaterial is a concept that has
been circulating in the fields of sociology and economics since the 1950s. There has been a relatively
slow evolution of the topic up until 2007, a key point-in-time for sociomaterialism and advances in
related research and application. In 2007, Orlikowski built upon her work from 1995 and sparked a
renewed interest in sociomaterial through the development of sociomaterialism and the concept of
entanglement.3 As previously discussed, constitutive entanglement is the intertwining of social and
material as a singular concept.3 Subsequently, several authors have debated the soundness of Or-
likowski’s constitutive entanglement and theorists have created several branching theories under
sociomaterialism including artefact, apparatus, affordance, constrain, object, entity, and actor-net-
work-theory.5,6
Modern takes on this Theory
Despite its 2007 resurgence, sociomateriality has had few modern advances apart from the afore-
mentioned viewpoints, notions, and debates.8 Regardless, its value is increasingly recognized in the
impact of technology in the modern world and is now be utilized in many fields of study after years
of being used primarily in organization and information systems literature. The constitutive entan-
glement described by Orlikowski is evident more than ever with humanity’s dependence on tech-
nology in nearly all aspects of everyday life. There are myriad benefits to the advances of technolo-
gy in the modern world including but not limited to worldwide connection, rapid communication
and dissemination, ease of access to information, improved productivity and efficiency of indus-
tries, and increased lifespan. However, there is a darker side to technology including vulnerability,
risk of breaches of sensitive personal information, diminished need for human rote memory and
knowledge, and human job loss as processes become automated. More significant concerns include
pandemics due to synthetic biology, climate change with geoengineering, production of weapons of
mass destruction via distributed manufacturing, and unpredictable artificial intelligence systems.9
While the benefits of technology outweigh the risks, individuals and organizations must be cog-
nizant of these risks to mitigate adverse outcomes. Sociomaterialism is the conceptual framework
surrounding these issues.
With the rapidly changing face of technology and its impact on humanity, sociomaterialism and so-
ciomateriality are among the most commonly discussed and debated conceptual framework and
theory applications in many fields of study and organizations. Applications of sociomaterialism are
also evident within the COVID-19 pandemic with mitigation measures, rapid transition from face-
to-face interaction to digital platforms, use of technology in continuing patient care without in-per-
son interaction, as well as significant educational responses in light of COVID-19.10
41
Other Examples of Where this Theory Might Apply
With technology’s far-reaching impact in many aspects of the modern world, the classroom and
clinical settings are prime locations for application of sociomaterialism as technology intersects these
arenas. Within the classroom, sociomaterialism is rooted within use of advanced technology (e.g.
computers, smartboards and projectors), online teaching practices or mobile learning, simulations,
use of social media to disseminate information or provide educational opportunities, open
educational resources via the Internet, and access to unlimited digital resources that benefit both the
educator and learner.11-14
Within the clinical setting, there is a plethora of medical literature applying sociomaterialism and so-
ciomateriality to both medical education and practice. Examples of application include multidisci-
plinary approaches to patient care, medical technology, distributed medical education (e.g. distance
education, web conferencing, video conferencing, online educational platforms and online communi-
ties), use of social media to disseminate evidence-based practices and free open access medical edu-
cation (FOAM), electronic medical records, use of smartphones and tablets, simulation-based learn-
ing, and digital resources.4,15-19
Limitations of this Theory
Limitations to sociomaterialism depend on the field of study or area to which the conceptual frame-
work is being applied. However, common limitations noted in the literature include the lack of ad-
dressing of problems in social inequality, strong versus weak versions of sociomaterialism, confusing
language of the framework itself, and ruminating design.
●Social Inequality: sociomaterialism and sociomateriality assumes equal access to technology
among all individuals and organizations. This limitation is highlighted in work using socioma-
terialism within the fields of education and literacy. This limitation is also seen in healthcare
applications, for example the use of a computerized algorithm that assumes equal access to
care
●Strong versus weak versions: weak sociomaterialism denotes separateness of social and mater-
ial while strong sociomaterialism does not.5
●Language and descriptors can be very difficult to understand.5 This, combined with multiple
definitions and overlapping theories, lends to significant confusion.
●Ruminating design: authors repeatedly debate the soundness of the foundation rather than fo-
cusing on the establishment of the framework and its application to individuals, relationships,
and organizations.
42
Returning to the case...
After Ms. Smith is quickly stabilized in the emergency department and transferred to the operating room, Shannon
asks Dr. Lee if they can discuss the case since she feels uneasy about what has happened. Dr. Lee agrees and they go to a
quiet room.
Shannon expresses that she feels guilty for not speaking up sooner and is frustrated that there were technology issues
that prevented clear communication. Furthermore, she feels that she was dismissed by Dr. Lee who rushed her off the
phone. Dr. Lee understands and states that he feels also guilty for missing the correct diagnosis, leading to a delay in
care. He apologizes to Shannon for dismissing her earlier and reiterates that there was a sick patient and he was faced
with competing urgent issues that needed attention. They agree on the importance of better communication in this and
decide to file a safety report with their respective leadership teams to help mitigate the risk of a similar incident in the
future. Within their meeting, Shannon and Dr. Lee unknowingly identified key issues applicable to sociomaterialism.
The lack of functional technology prevented both parties from doing their job correctly and led to frustration. Shannon
was unable to communicate her concerns and Dr. Lee, with minimal information, switched to another material (ECG)
to decide how he would act next. Furthermore, this technology glitch changed the way that both the physician and
paramedic interacted. Similarly, the environments that they both were in also influenced their behaviours and interac-
tion. For example, Dr. Lee was paged overhead to attend to another sick patient, despite being within eyesight of the pa-
tient’s room and available to immediately help.
Beyond this conversation, there are other factors at play in this constitutive entanglement. So, there you have it, a
practical example of the complexities that involve material and social in everyday learning and practice. Sociomaterial-
ism supports that medical practice is a collective sociomaterial enactment and not a question solely of an individual’s
skills. It decenters the human as the focus to allow for a deeper exploration of the complex, messy and non-linear rela-
tionships between materials and social practices.20
43
References
1. Lexico. “Social.” Published 2020. Accessed August 5, 2020. https://www.lexico.com/en/definition/
social
2. Lexico. “Material.” Published 2020. Accessed August 5, 2020. https://www.lexico.com/en/
definition/material
3. Orlikowski WJ. Sociomaterial practices: Exploring technology at work. Organ Stud.
2007;28(9):1435-1448. doi:10.1177/0170840607081138
4. Jones M. A matter of life and death: Exploring conceputalizations of sociomateriality in the context of
critical care. MIS Q. 2014;38(3):895-925.
5. Bavdaz A. Past and recent conceptualisations of sociomateriality and its features: Review. Athens J Soc
Sci. 2017;5(1):51-78. doi:10.30958/ajss.5-1-3
6. Martine T, Cooren F. A relational approach to materiality and organizing: The case of a creative idea.
IFIP Adv Inf Commun Technol. 2016;489(January 2016):143-166. doi:10.1007/978-3-319-49733-4
7. Leonardi PM. Theoretical foundations for the study of sociomateriality. Inf Organ. 2013;23(2):59-76.
doi:10.1016/j.infoandorg.2013.02.002
8. Hultin L. On becoming a sociomaterial researcher: Exploring epistemological practices grounded in a
relational, performative ontology. Inf Organ. 2019;29(2):91-104. doi:10.1016/j.infoandorg.2019.04.004
9. Global Priorities Project, Future of Humanity Institute University of Oxford, Oxford Martin School,
University of Oxford, Centre for the Study of Existential Risk University of Cambridge. Unprecedented
Technological Risks.; 2014. doi:10.1007/978-3-642-56958-6_12
10.Cleland J, Tan ECP, Tham KY, Low-Beer N. How Covid-19 opened up questions of sociomateriality in
healthcare education. Adv Heal Sci Educ. 2020;25(2):479-482. doi:10.1007/s10459-020-09968-9
11.Bolldén K. The emergence of online teaching practices: A socio-material analysis. Learn Media Technol.
2016;41(3):444-462. doi:10.1080/17439884.2015.1044536
12.Mifsud L. Mobile learning and the socio-materiality of classroom practices. Learn Media Technol.
2014;39(1):142-149. doi:10.1080/17439884.2013.817420
13.Hopwood N, Rooney D, Boud D, Kelly M. Simulation in higher education: A sociomaterial view. Educ
Philos Theory. 2016;48(2):165-178. doi:10.1080/00131857.2014.971403
14.United States Department of Education. Use of technology in teaching and learning.
15.Fenwick T. Sociomateriality in medical practice and learning: Attuning to what matters. Med Educ.
2014;48(1):44-52. doi:10.1111/medu.12295
16.MacLeod A, Kits O, Whelan E, et al. Sociomateriality: A theoretical framework for studying
distributed medical education. 2016;44(0):0-19.
17.Abrandt Dahlgren M. Perspectives on co-learning: Practices as sociomaterial entanglements.
18.McMurtry A. Reframing interdisciplinary and interprofessional collaboration through the lens of
collective and sociomaterial theories of learning. Issues Interdiscip Stud. 2013;98(31):75-98.
19.Barrett M, Oborn E, Orlikowski W. Creating value in online communities: The sociomaterial
configuring of strategy, platform, and stakeholder engagement. Inst Oper Res Manag Sci. 2016;27(4).
doi:10.1287/isre.2016.0648
20.Goldszmidt M. When I say… sociomateriality. Medical education. 2017 May;51(5):465-6.
21.MacLeod A, Ajjawi R. Thinking sociomaterially: Why matter matters in medical education. Academic
Medicine. 2020 Jun 1;95(6):851-5.
44
45
ANNOTATED BIBLIOGRAPHY
1. Bavdaz A. Past and recent conceptualisations of sociomateriality and its features: Review.
Athens J Soc Sci. 2017;5(1):51-78. doi:10.30958/ajss.5-1-3
Aleksandra Bavdaz dives into the topic of sociomaterialism in an extensive review. The review
covers a number of topics including the evolution of definitions of material, social, and technology.
It also describes varying viewpoints on sociomaterialism, a discussion of research junctures and
associated metatheories, studies of the features of the conceptual framework. Finally this paper
reviews examples of real world application and highlights points for further research.
2. Jones M. A matter of life and death: Exploring conceputalizations of sociomateriality in the
context of critical care. MIS Q. 2014;38(3):895-925.
This paper provides a detailed background on sociomateriality including historical perspective and
key features/notions of the conceptual framework including materiality, inseparability, relationality,
performativity, and practice. Jones also provides a comprehensive literature review surrounding so-
ciomaterialism from 2007-2013 having found 146 papers that are outlined in table format. After re-
viewing sociomaterialism, Jones then goes on to apply the conceptual framework to the “implemen-
tation of a computer-based clinical information system in a 25-bed critical care unit” and describes
how each of sociomatieralism’s core ideas play a role in the case example. The article concludes
with a discussion of sociomaterialism’s influence in the information systems world and dives deep-
er into the conceptual framework’s importance of the principle of the interaction of technology and
humans.
3. Leonardi PM. Theoretical foundations for the study of sociomateriality. Inf Organ.
2013;23(2):59-76. doi:10.1016/j.infoandorg.2013.02.002
Paul Leonardi highlights two theoretical foundations of sociomateriality: agential realism and criti-
cal realism. For agential realism, the paper discusses the foundation of the theory and reviews shift-
ing definitions. The paper then reviews challenges of agential realism and describes how these lead
to the development of critical realism as a solution to these problems. The paper also provides
graphical descriptions of the structural approach of technologies from 1986 to 2000 and key differ-
ences between agential realism and critical realism. The paper concludes with comparing and con-
trasting the two theories.
4. MacLeod, A. and Ajjawi, R., 2019. Thinking sociomaterially: Why matter matters in medical
education. Academic Medicine. DOI: 10.1097/ACM.0000000000003143
This primer introduces sociomaterialism and its role in health professions education and scholar-
ship. It begins with a coherent and readable overview of the ontological, epistemological, axiologi-
cal, and methodology.
A Case
Sarah has just finished her ultrasound fellowship and is working at a new hospital in the Emergency Department.
She has discovered that many of her new partners are not familiar with or comfortable using bedside ultrasound in
clinical practice. When she inquires about this, many of her coworkers mention that they were educated prior to
2006, when ultrasound became incorporated into residency training as part of the required curriculum for resi-
dents.
Sarah would like to design a certification program for her colleagues to help them become more comfortable with
performing and interpreting ultrasound in clinical practice. She would like to develop a curriculum initially with
some core ultrasound applications to teach her colleagues how to perform and interpret basic bedside ultrasound
studies and then expand to other imaging applications. How can the Logic Model of Program Evaluation help her
design a program? What activities can be planned and what outcomes could be measured to ensure success of her
program?
46
CHAPTER 7
Authors: Kathryn Fisher, MD, MS; Jeanne Macleod, MD; Sarah Kennedy, MD
Editors: Benjamin Schnapp, MD, MEd; Teresa Chan, MD, MHPE
Logic Model of Program Evaluation
47
OVERVIEW
The logic model is a conceptual tool that can be used when facilitating program planning,
implementation, and evaluation. This tool is designed to examine a program’s resources, planned
activities, and proposed changes or goals in an organized fashion. It describes the linkages between
resources, activities, outputs, outcomes, and their impact on the program as a whole. It provides a
model of how a program might function under certain situations.1
The logic model is represented visually in four main sequential components including inputs, activi-
ties, outputs, and outcomes. These comprise two main domains: planned work and intended out-
comes. Planned work includes inputs and activities while intended outcomes reflect the outputs and
outcomes. Outcomes can be measured as immediate, intermediate, and long-term. Some sources also
suggest a fifth component, a measurement of impact, at the end of the model in lieu of, or in addition
to, long-term outcomes.2 In business applications, many logic models also contain a schematic of ex-
ternal influences as arrows into each of the components to show how each of these external factors af-
fects each of the steps of the model.
This model has been used in initial program design and planning, in program evaluation and restruc-
turing, and for other individual or group evaluative processes. It provides a structured framework to
systematically evaluate program components and to communicate with team members. The logic
model is a tool applied to facilitate acquisition of the information necessary in decision making as it re-
lates to evaluation and restructuring. The logic model is specifically useful in determining evaluation
for medical education programs.3 Figure 1 below depicts the workflow of a typical logic model where
a program’s intended inputs are linked to the program activities, and then to the program outputs,
which should result in the intended outcomes. In figure 1, we depict how the unintended outcomes
are not usually measured by the logic model, which focuses on the intended outcomes.
Figure:
The Logic Model - a se-
ries of “if/then” state-
ments that link the logic
of the program and its
elements.
Note that logic models
are notorious for not ac-
counting for unintended
consequences or out-
comes.
MAIN ORIGINATORS OF THE THEORY
Edward A. Schuman
Joseph S. Wholey
Background
The early ideas of logic models were first raised in a 1967 book by Edward A. Schuman about evaluative
research.5 Over the next decade, two types of logic models emerged. One called Theory of Change and
the other termed Program Evaluation or Outcomes Model. The Theory of Change model is more concep-
tual and provided the foundation for the Program Evaluation Model, which is more operational.4
The concept of a logic model was previously captured in other structures and under different variations
including “Chains of Reasoning,” “Theory of Action,” and “Performance Framework.”1 Bickman 1987
introduced logic models as a tool for program evaluation that emphasized program theory.6
The first publication using the term “Logic Model” was by Joseph S. Wholey (1983).7 McLaughlin and
Jordan3 were also champions of the logic model approach. The first developers of the logic model came
from business, public sectors, international non-profit sectors, and other program evaluators. Logic
models did not become widely used until the United Way published Measuring Program Outcomes in
1996.8 This article was important in establishing the terms and structure used today for developing Logic
Models. The W.K Kellogg Foundation published a widely available Logic Model Development Guide
which has been used for public policy and healthcare planning.9 Over the last decade logic models have
also been used for medical education program evaluation.
Inputs can be seen as certain resources necessary to operate the program.3 Inputs include resources ded-
icated to or consumed by the program and can include financial resources and funding, protected time
for faculty or staff, expertise of faculty and staff, administrative support, and physical resources such as
facilities and equipment.
If a program has access to inputs, then it can use them to operate planned activities.3 Activities represent
what the program does with the inputs it has to fulfill its mission. Activities may include any combina-
tion of needs assessments, teaching, curriculum design, planning of sessions, faculty development, de-
velopment of systems, or performance evaluations. These activities are dependent on the program’s
mission.
If the planned activities are accomplished, then the program will deliver the intended product or service
output.3 The outputs section in logic models describes the direct, measurable outputs of the activities.
This can include demographics such as number of participants in a program’s activities, number who
completed a certain curriculum, or program metrics such as number of programs, time in existence, or
number of graduates of a program.
48
If the planned activities are accomplished to the extent represented in the outcomes, then the organi-
zation will be affected in certain ways as described by the outcomes.3 Outcomes can be measured
immediately, as well as in the intermediate and long-term time frames and are generally split into
these time designations. They look at the benefits for participants during and after program activi-
ties. These can include increased knowledge or skill, satisfaction with quality of activities, or im-
provement in evaluations. Additionally, outcomes can be measured by various metrics dependent on
the program for clinical, teaching, program, or academic success following the implementation of ac-
tivities. Awards, productivity, shared resources, and increased involvement can also be measurable
outcomes.
Finally, if the benefits of the program are achieved then the activities implemented as part of the pro-
gram will have an impact on external factors such as an organization or system.3 This can relate to
impact on an industry or system based or impact it has on the community, environment, or in-
frastructure.
Modern takes on this Theory
The Logic Model is a tool that can facilitate communication and can be used for idea sharing, identi-
fying projects critical to goal attainment. The logic model can identify if there are implausible link-
ages among program elements or redundant pieces.1 Benefits of the logic model include gaining a
common understanding and expectations of resources, their allocation, and results. In the past few
decades, the logic model has been applied to various applications in medical education and health-
care. Generally, the model is most widely used for innovations and new program design or in evalu-
ation of current programs. Program managers are using the logic model to argue how or why the
program is meeting a specific customer need, whether that customer is in a private sector or the cus-
tomer is a medical learner.1 In a more cognitive sense, the logic model is used to facilitate the process
of thinking through faculty development and other large-scale initiatives.3 Other uses have been
adopted on a larger system scale for healthcare systems innovations.1 They have also been used on a
larger scale in the public health workforce to support ongoing program planning and evaluation and
for communication between divisions.10 Portfolio evaluation, or the evaluation of multiple projects
with a common purpose, also benefits from the use of logic modeling as a visual tool.11
Logic models have been used as a way to determine consensus among leadership or with stakehold-
ers in a certain situation, as one can examine both the inputs and the desired outcomes and how they
will be measured. This approach can be applied to medical education in the setting of institutional
self-review.12 The World Federation for Medical Education utilized a logic model applied to further
define and evaluate each of their accreditation standards. In this specific case, the logic model was
used both for standard setting and consensus of their standards, but also as an evaluative tool.12
Other Examples of Where this Theory Might Apply
Van Melle et al proposed how to use the Logic Model in Program Evaluation for Competency-Based
Medical Education (CBME).13-15 The authors provide an outline of how to use a logic model to focus
49
CBME program evaluation, how to make a program evaluation scholarly, and how to build capacity for
program evaluation. They used the Logic Model framework to provide an outline on how to evaluate
CBME initiatives in a residency program. This is broken down into a flow chart of an Outcomes Logic
Model. First step being the Purpose of CBME, then resources to implement (Inputs), followed by what
Activities are critical for CBME. The final step is that the program results are broken down into Outputs:
the description of competencies and Outcomes: proximal and distal. The proximal outcome being en-
hanced readiness for practice and the distal outcome being improved patient care.16
Limitations of this Theory
The Logic Model’s main limitation is that it may lead to over-simplification and miss many of the
unintended consequences because of its focus on the program’s desired outcomes. Medical educational
programs are often complex and don’t always follow a linear path. To overcome this limitation the Logic
Model needs to be well designed. The creators of the model should have a thorough understanding of
how change works in the educational program being evaluated. Both intended and unintended
outcomes should be anticipated, and feedback loops must be incorporated into the model to address
these complexities. The Logic Model design needs to be flexible and dynamic in order to integrate
unexpected complexities. Educators and researchers need to be prepared to revise the model as the
program is being implemented. Therefore, the development and revision of a logic model can be a time-
consuming process.
Complexity can be built into the Logic Model by the addition of multiple tiers. Mills et al attempt to
address this problem in their 2019 article.10 The authors propose a typology of logic models. They
categorize logic models into four types, ranging from simple (type 1) to the most complex (type 4). The
type 4 logic models attempt to provide more insight into the interactions between interventions and
context (social, political or cultural factors in the environment where the program exists).
The greatest challenge is to find the balance between precision, which may require many data points,
with the creation of a concise, easy to understand model.
Returning to the case...
Sarah uses the Logic Model to plan a curriculum for her coworkers to obtain initially core and then
global ultrasound certification in a step-wise approach. See Figure 2 for a diagram of her logic model.
She creates a pre-survey and pre-test to see initial attitudes and knowledge. She then creates educa-
tional opportunities to teach her coworkers. She has a post-survey and post-test to evaluate how be-
haviors, knowledge, and attitudes have changed over the course of a year. Sarah makes a goal of certi-
fying 75% of her colleagues in core ultrasound applications and then expands her program to in-
clude other imaging applications.
50
References:
1. McLaughlin, J.A. and G.B. Jordan, Logic models: a tool for telling your programs performance sto-
ry. Evaluation and Program Planning, 1999. 22(1): p. 65-72.
2. Developing a Logic Model or Theory of Change. [cited 2020 May 22]; Available from: https://ct-
b.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/logic-
model-development/main.
3. Otto, A.K., K. Novielli, and P.S. Morahan, Implementing the logic model for measuring the value
of faculty affairs activities. Acad Med, 2006. 81(3): p. 280-5.
4. Frye, A.W. and P.A. Hemmer, Program evaluation models and related theories: AMEE guide no.
67. Med Teach, 2012. 34(5): p. e288-99.
5. Schuman, E., Evaluative Research Principles and Practice in Public Service and Social Action Progr.
1968, New York: Russel Sage Foundation
6. Bickman, L., The functions of program theory. New Directions for Program Evaluation, 2004. 1987:
p. 5-18.
7. Wholey, J., Evaluation and Effective Public Management. . 1983, Little Brown.
8. Measuring Program Outcomes: A Practical Approach ed. U.W.o. America. 1996.
9. Logic Model Development Guide, ed. W.K.K. Foundation. 2004.
10. Glynn, M.K., et al., Strategic Development of the Public Health Workforce: A Unified Logic Model
for a Multifaceted Program at the Centers for Disease Control and Prevention. Journal of public
health management and practice : JPHMP, 2019.
11. Wu, H., et al., Using logic model and visualization to conduct portfolio evaluation. Evaluation and
Program Planning, 2019. 74: p. 69-75.
12. Tackett, S., J. Grant, and K. Mmari, Designing an evaluation framework for WFME basic standards
for medical education. Med Teach, 2016. 38(3): p. 291-6.
13. Railer, J., et al., Using outcome harvesting: Assessing the efficacy of CBME implementation. J Eval
Clin Pract, 2020.
14. Van Melle, E., et al., A Core Components Framework for Evaluating Implementation of Competen-
cy-Based Medical Education Programs. Acad Med, 2019. 94(7): p. 1002-1009.
15. Melle, E.V., Using a Logic Model to Assist in the Planning, Implementation, and Evaluation of Ed-
ucational Programs. Acad Med, 2016. 91(10): p. 1464.
16. Van Melle, E. Program Evaluation for CBME: Are we making a difference? . in The International
Conference on Residency Education. 2016. Niagra Falls, Ontario, Canada.
17. Campbell, J.R., et al., Building Bridges Between Silos: An Outcomes-Logic Model for a Multidisci-
plinary, Subspecialty Fellowship Education Program. Acad Pediatr, 2015. 15(6): p. 584-7.
51
52
ANNOTATED BIBLIOGRAPHY
1. McLaughlin, J.A. and G.B. Jordan, Logic models: a tool for telling your programs perfor-
mance story. Evaluation and Program Planning, 1999. 22(1): p. 65-72.1
This paper was one of the first to outline in detail, the practical applications of the Logic Model. It
was intended to explain to program managers in the public and private sectors how to measure
and evaluate a business program and how to use that knowledge to improve a program’s effec-
tiveness. By utilizing clearly outlined figures and tables, these authors provided a detailed expla-
nation on how to build a Logic Model for business managers.
2. Logic Model Development Guide, ed. W.K.K. Foundation. 2004.9
This Kellogg foundation document outlined important definitions of the Logic Model as a method
of program evaluation. “The program logic model is defined as a picture of how your organiza-
tion does its work- the theory and assumptions underlying the program. A program logic model
links outcomes (both short and long term) with program activities/processes and the theoretical
assumptions/principles of the program.”
3. Otto, A.K., K. Novielli, and P.S. Morahan, Implementing the logic model for measuring the
value of faculty affairs activities. Acad Med, 2006. 81(3): p. 280-5.3
Otto et. al in 2006 published the first landmark article in Academic Medicine suggesting the use of
logic models in medical education. They suggested use of logic models for measuring the contri-
bution of faculty affairs and development offices to the recruitment, retention and development of
a medical school’s teaching faculty in efforts to reward faculty for teaching. They nicely review the
structure of a logic model overall and give an example of its use in a visual format with a compre-
hensive associated list of components in each category. Use of the logic model is suggested to fa-
cilitate the process of thinking through the entire faculty development process.3
4. Frye, A.W. and P.A. Hemmer, Program evaluation models and related theories: AMEE guide
no. 67. Med Teach, 2012. 34(5): p. e288-99.4
AMEE Guide No. 67. This paper takes a broader view of various program evaluation models. It is
useful because it compares and contrasts several different models. In addition to the Logic Model,
it also discusses the experimental/quasi-experimental model, the Context/Input/Process/Prod-
uct Model (CIPP model), and Kirkpatrick Model. It delves into the strengths and weaknesses of
each type of model and how they can be applied to Medical Education. The authors in this paper
provide a good description and analysis of each of the four essential elements of the Logic Model.
It provides various medical education centered examples of each of these elements.4
A Case
“I’m worried about Paul’s scores, they are concerning and put him at risk to not pass boards. I just don’t get it, he is
a solid performer in the department”
Most of the faculty at the clinical competency committee meeting nod in agreement as they review the inservice
exam scores.
“What can we do about it? He seems so clinically competent when caring for patients. He always gets my pimp
question about patients we are caring for correct and asks great follow-up questions. How can he be struggling so
much on a test when he clearly knows the answers?” states another faculty member.
The committee chair comments “he probably needs to be placed on a corrective action plan to help him. He probably
needs to do more practice questions and a few practice tests. If he can improve his score on a practice test in a few
months then we can look at taking him off the plan”.
Another member remarks “I’m not sure that is the answer. I just pulled up his progress through the practice ques-
tion bank, he has completed nearly 90% of the questions, far more than most of the other residents. He obviously
needs test taking help, but I feel like there is more we can do to help bring out his knowledge in the testing setting.”
“Let me think about it a bit more,” added another faculty member, “but can you believe Peter’s score?! He can be
awful to work with in the department, how did he score in the top 10%?”
53
CHAPTER 8
Authors: Drew Kalnov, DO; Jennifer Whitfield, MD; Sophia Lin, MD
Editor: Abra Fant, MD, MS; Teresa Chan, MD, MHPE
Situated Cognition
The case we presented is a common problem in student and resident training, a disconnect in one's per-
ceived knowledge, clinical competency and test taking abilities. Often some of the highest performing
learners in the clinical setting struggle to translate this to static questions and tests, while others excel in
test taking but struggle to apply that knowledge in the clinical setting. What education theory can help
explain why many learners perform in this manner, and what are some methods that can be used to im-
prove their performance across all assessment mediums?
54
MAIN ORIGINATORS OF THE THEORY
Lev Vygotsky
Other important authors:
Alexi Leon’tev;
John Seely Brown
Lucy Schuman
OVERVIEW
Situated cognition is an educational theory that proposes knowledge cannot be separated from the
environment and situations in which it is learned and applied. Knowledge is not self-contained.
Understanding physical, social and cultural contexts in which concepts are used, and teaching these
concepts within these contexts, is paramount for students to truly master knowledge.
This theory contrasts with the more traditional information processing theory in which learning is
thought to occur when decontextualized ideas are committed to long-term memory. With information
processing, students are taught information in a classroom setting, in isolation from the environment
in which it is to be used. This information relies solely on the learner and is independent of
environment. It is later retrieved from the learner’s memory during situations in which it is used,
making learners “storage-retrieval systems”.1 Ideas taught using this traditional theory are incomplete,
however, because their full meaning is dependent on context. With situation cognition, information is
truly learned only in the context in which it is used. Information is intertwined with situation. How a
learner perceives the information taught depends on both the environment in which it is taught as
well as the environment in which it is to be used. Learners must be exposed to realistic situations
requiring utilization of knowledge. It is only through this exposure to concepts in situ that an
individual can truly understand what is being taught. With situated cognition, the learner is a
“perceiving-acting system”1 who can more easily draw on adaptable knowledge to apply to more
varied situations.
Background
Situation cognition was first formally described in the mid-1980s as a result of collaboration between the
Institute for Research and Learning, a multi-disciplinary think tank tasked with studying the process of
learning and the XEROX Palo Alto Research Center.2 However, its origins lie in earlier theories from a
broad range of disciplines. These theories include phenomenological philosophy from philosophy, cul-
tural-historical activity theory and ecological psychology from psychology, American pragmatism from
education, enactivism from theoretical biology, embodiment from physiology, and situation semantics
from linguistics.
In their collaboration, Seely Brown and colleagues sought to determine if knowledge could be learned as
a mental representation of a concept within an individual, independent of context, and whether or not
this internalization is requisite in successfully mastering complex human behaviors. In their research,
Seely Brown and colleagues liken the acquisition of knowledge to the acquisition of vocabulary as stud-
ied by Miller and Gadea. While a child can certainly learn words and their dictionary meaning without
being exposed to use of these words in real-world conversations, this method is less efficient and less ef-
fective than learning these words in the contexts in which they are normally used. Seely Brown et al. also
compare knowledge to tools. To achieve a full “implicit” understanding of a tool’s function and the set-
tings in which it’s used, a learner must actually use the tool in situations it was designed to be used. A
community develops amongst individuals who use a tool and from this, culture and a community of
practice form. This culture also adds to the full conceptual understanding of a specific tool. Seely Brown
and colleagues posit that students need exposure to knowledge being applied by real-life practitioners.
Learners must also engage in “authentic activity,” both basic and more advanced situations. When at-
tempts at translating authentic activity to activities that are more easily accomplished in a classroom,
knowledge becomes limited to the domain of the classroom, making it less easily extracted in real-life
domains.4,5
As a more effective alternative to traditional pedagogy practices, Seely Brown et al. proffer cognitive ap-
prenticeship. Concepts are introduced within the framework in which they are to be applied in the real
world. As students master fundamentals, they then progress to more autonomous activity, all under the
tutelage of a practitioner who uses these concepts in authentic domain activities. By using their basic
understanding of concepts taught in real-world situations, their knowledge further evolves. Apprentice-
ship also organically leads to “enculturation” within a community of practice. Integral to a community
of practice are social interaction, social constructs of knowledge, and collaborative. Cognitive appren-
ticeship can be applied broadly across multiple fields and is especially useful in disciplines involving
higher-order human activities.
Modern takes on this Theory
Situated cognition theory has played a starring role in the evolution of modern medical education, par-
ticularly at the undergraduate level. The traditional model of reliance on didactics, written testing, and
acquisition of factual knowledge that once defined medical school curricula, particularly in the 1st and
55
2nd (often called “preclinical”) years, has largely disappeared. Recognizing the need for a holistic educa-
tional framework, in which the student physician acquires knowledge not only from a textbook but
within the dynamic clinical environment, educators have developed novel curricula that embrace the
situated cognition theory. The following examples illustrate use of this theory in recent adaptations in
medical education:
Problem-based learning (PBL)6: A massive shift away from lecture halls to PBL has occurred recently in
medical education and is a model example of situated cognition in practice. Students are provided with
a case, initially simple and appropriate to the learners level, and are given more information as they
progress through the case, in an attempt to provide quality care to the simulated “patient” This process
is necessarily iterative; students must adapt and learn based on new and increasingly complex informa-
tion from the hypothetical patient, context and clinical environment. Thus is the learning situational and
acquired in the context of the patient-provider relationship.
Preceptor-style clinical learning: The core of this theory is that education must take place in authentic
environments, Preceptorships allow the student to learn from an expert in the chaotic and complex
“real” patient care setting. Skills such as shared decision - making and delivery of bad news are as in-
valuable as they are impossible to learn outside of a situated and authentic setting.
Patient-centered learning7: Patient-centered care focuses on patient participation, the relationship be-
tween the patient and the provider, and the context and accessibility of the care, and is now the gold
standard for health care provision. medical education has necessarily become patient- centered as a re-
sult. Clinical exposure for students starting early in the first year and opportunities to follow patients
longitudinally are novel applications of situated cognition, allowing the student to learn factual medical
knowledge while concurrently understanding how the patient is affected by the disease within the larg-
er sociocultural context. Additionally, there has been a recent emphasis in residency training programs
on the use of patient feedback as an opportunity for reflection and improvement, again adopting the sit-
uated cognition theory that “book” knowledge is insufficient to learn excellent clinical care if the patient
is unable to receive the care compassionately, sensitively, and professionally.
Other Examples of Where this Theory Might Apply
Situated cognitive learning is occurring in clinical settings by a matter of course. The constant and com-
plex interplay of the patient and the environment, the other staff and providers, as well as the experi-
ences of the learner and educators, necessarily both affects the learning process and informs it. The in-
clusion of timely reflection and feedback is essential to learning in this environment as well, as the learn-
er must be allowed to identify how and why the care of the patient changed as the interaction devel-
oped, and what he or she learned from that experience that will improve his or her future practice.
In the classroom setting, simulations that allow for problem - based learning, in which information
about the patient and the context are dynamic, are prime examples of the situated cognition theory at
work. For example, emergency medicine fellowships in wilderness and global health use simulated case
scenarios to teach fellows how to care for patients in low - resourced and austere settings. At this post -
56
graduate level, the learner is highly educated in the field of emergency medicine but only in the context
of the relatively highly-resourced western emergency department. For example: During a simulation, we
may create a precipitous childbirth case with complicating shoulder dystocia - a condition the fellows
should be able to manage. However, we add in a power outage and remove some equipment that would
normally be available or place the scenario in a rural clinic with long transport times to a hospital. Such
adaptations allow the fellow to learn in a dynamic and innovative fashion, in a scenario essential to the
core competency of the fellowship.
Limitations of this Theory
There are several limitations to practically adapting a situated cognition model in medical education.
First, adaptation of traditional medical school structure to accommodate problem -based learning, longi-
tudinal patient interactions, and early preceptorships - activities that embrace situated cognition theory -
may be logistically and culturally difficult. Such a shift requires not only educators who are well - versed
in these learning styles, but also a willingness to shift a well - worn and ingrained paradigm of medical
education via lecturing, Socratic - style questions, and written tests. Moreover, placing learners in clini-
cal situations or even high - tech simulation labs can be challenging depending on availability and cost
of such resources. Such opportunities are also time - consuming, often requiring travel, and may be de-
pendent on unreliable patient volumes.
Another limitation is effectively evaluating learning interventions that use situated cognition: Without a
traditional test or score sheet, the ability to measure acquisition of knowledge gained using situated
cognition may be difficult and time - consuming. One must rely on direct observation, OSCE - style sim-
ulations, and qualitative data to evaluate within this theoretical context.
Returning to the case...
Faculty continued to discuss multiple residents' performance and ultimately returned to the discussion of how to
address perceived performance deficiencies.
“In addition to individual plans for improvement, do we need to be looking at our curriculum and how our weekly
conference is going?”
Since many of the faculty are also on the curriculum and conference committees, this discussion amplified and be-
gan to look systemically at the manner in which much of the programs leaning is being delivered.
“You know, several of us have been discussing the need for more integrated simulation and small group case dis-
cussions” one faculty remarked. “We seem to be very heavy on delivered lectures without always making full con-
nections to the clinical application of the knowledge. I suspect that providing a more immersive experience may be
beneficial for both learners like Paul and Peter.”
To further address the variety of learners within the program and in hopes to further engage faculty in-
volvement in conference, program leadership looked to invoke principles related to situated cognition.
By increasing the use of clinical case discussions in conference, faculty and residents felt that the infor-
mation was more relatable and applicable to clinical situations. Additionally on shift, there was in-
57
creased effort to relate clinical situations to common board-style questions that the learners will en-
counter.
Through these changes, both learners and educators felt there was significant improvement in
knowledge translation, both from conference topics to the clinical setting but also through utilizing
clinical situations to cement the application of knowledge and allow it to be recalled based on the sit-
uational experience.
While it will take some time and additional evaluation to determine if these changes result in im-
provement across the board, both with clinical application of knowledge and translating that to
knowledge recall in a standardized testing environment, initial indicators appear promising. By pro-
viding a learning experience drawing on situated cognition, Paul has improved his practice test
scores significantly while on an improvement plan and Peter has been receiving significantly better
on-shift evaluations and feedback.
References
1. Artino Jr, Anthony R. It's Not All in Your Head: Viewing Graduate Medical Education Through the
Lens of Situated Cognition. Journal of Graduate Medical Education 2013: 5(2): 177-179.
2. Brown, J. S.; Collins, A.; Duguid, S. (1989). "Situated cognition and the culture of learning". Educa-
tional Researcher. 18 (1): 32–42.
3. Hearn J, Dewji M, Stocker C, Simons G. Patient - centered medical education: A proposed defini-
tion. Medical Teacher 2019, 41(8):934-938.
4. Hall, Rogers. "Representation as shared activity: Situated cognition and Dewey's cartography of
experience." The Journal of the Learning Sciences 5.3 (1996): 209-238.
5. Robbins, Philip, and Murat Aydede. "A short primer on situated cognition." The Cambridge handbook
of situated cognition (2009): 3-10.
6. Servant-Miklos VF, Norman GR, Schmidt HG. A short intellectual history of problem-based learn-
ing. The Wiley Handbook of Problem-Based Learning. 2019 Apr 3:3-24.
7. Stewart M, Brown JB, Weston W, McWhinney IR, McWilliam CL, Freeman T. Patient-centered med-
icine: transforming the clinical method. CRC press; 2013 Dec 28.
58
59
ANNOTATED BIBLIOGRAPHY
1. Artino Jr, Anthony R. It's Not All in Your Head: Viewing Graduate Medical Education Through
the Lens of Situated Cognition. Journal of Graduate Medical Education 2013: 5(2): 177-179. https://
doi.org/10.4300/JGME-D-13-00059
This manuscript provides a concise and clear summary of the situated cognition theory, specifically
how it differs from information processing theory, and then discusses how and which medical educa-
tion practices use the theory. The article clearly defines the theory and discusses how it is particularly
useful in medical education. Moreover, the author discusses the challenges of researching the efficacy
of medical education based in situated cognition and provides examples of how such research can be
done effectively, i.e. reliance on mixed - methods approach and emphasis on qualitative data.
2. Brown, J. S.; Collins, A.; Duguid, S. (1989). "Situated cognition and the culture of learning". Edu-
cational Researcher. 18 (1): 32–42. Link here
This manuscript by Brown et al. is amongst the first and most referenced works firmly introducing
the concept of situated cognition as a learning theory. The authors clearly define the framework for
the theory including examples to illustrate the concept that knowledge and thus learning is situated
in the context and activities where it is acquired. The fundamental argument of the work is that edu-
cation has traditionally relied on the explicit at the sacrifice of the implicit instead of creating a cohe-
sive balance.
3. Hearn J, Dewji M, Stocker C, Simons G. Patient - centered medical education: A proposed defin-
ition. Medical Teacher 2019, 41(8):934-938. DOI: 10.1080/0142159X.2019.1597258
The aim of this paper is to review literature on patient- centered medical education and arrive at a
standard definition and description of this learning style. The authors first identify and define “pa-
tient-centered care” for the reader, recognizing that this model of health care has become the gold
standard internationally. As a result, patient - centered medical education has become essential. The
authors identify it as any learning opportunity that focuses on the patient’s input, socio- cultural con-
text, and health needs. Introduction of medical students to patients early in their career, as well as
opportunities for them to interact longitudinally with patients, are used as examples, as well as the
novel inclusion of patients in development of medical school curricula and selection of medical stu-
dent applicants.
A Case
John is a medical student on a rotation in the Emergency Department. On a busy Friday evening shift in the
Emergency Department, John asks Dr. Smith if he can see a new patient with a chief complaint of “shortness of
breath.”
“Of course,” Dr. Smith replies, and John goes to assess the patient.
Dr. Smith is then handed the patient’s ECG, which shows an antero-lateral ST-Elevation Myocardial Infarction
(STEMI). The team begins to mobilize and the interventional cardiologist is paged.
Both Dr. Smith and John note that the patient is short of breath with peripheral edema and his blood pressure is
low. Dr. Smith shows John the patient’s ECG and discusses with the patient what is currently going on and that it
appears the patient needs to undergo emergent cardiac catheterization. After stabilization and resuscitation of the
patient, the patient is transferred to the catheterization suite for percutaneous coronary intervention.
After Dr. Smith and John return to their workspace, Dr. Smith asks “Do you have any questions about the case we
just saw?”
John admits that he has not seen a STEMI patient before and is confused about how the patient’s symptoms of
shortness of breath and hypotension fit.
In an effort to simplify the concept for John, Dr. Smith confidently and clearly states that “the antero-lateral STE-
MI caused a large area of infarct in the left ventricle and this led to cardiogenic shock.”
John is confused and tells Dr. Smith that he still does not understand what exactly happened and is also struggling
with the concept of cardiogenic shock as he has never taken care of a patient with it before.
It is nearing the end of Dr. Smith’s shift and she is frustrated that she cannot convey this seemingly simple concept
to John. Dr. Smith prints out a review article on cardiogenic shock from the American Heart Association and asks
John to read it while she finishes up her shift.
John senses Dr. Smith’s frustration and says that he will look it over and thanks her for her time.
Both of them are left frustrated and wondering how the situation could have gone better.
60
CHAPTER 9
Authors: James Hoffman, MD; Ricciardo Bianchi, PhD; Muhammad Durrani, DO
Editor: Michael Gottlieb, MD
Ausubel’s Meaningful Learning Theory
61
MAIN ORIGINATORS OF THE THEORY
David P. Ausubel, MD, PhD
Other important authors or works:
Joseph D. Novak, PhD
OVERVIEW
Educational psychology, the study of the social, emotional, and cognitive processes that occur in
learners, has come a long way in the past 70 years.1 The development of behaviorism in the 1950s
considered learning in the form of conditioning, with a focus on observable and measurable external
factors. However, this theory did not account for cognitive processes and the internal factors
influencing the learner. This led to a shift in education theory towards a focus on cognitive processes
and constructivist ideas. David Ausubel, an American psychologist, contributed greatly to this field by
developing one of the most profound educational theories, Meaningful Learning Theory, first
published in 1963.2
Ausubel advocated that the most important factor in learning is that which the learner already knows.
“Meaningful learning occurs when the learner interprets, relates, and incorporates new information
with existing knowledge and applies the new information to solve novel problems”.3 External factors,
such as one’s learning environment, were still considered significant, but the emphasis was primarily
on internal factors and the individual learner. Previously, classroom teaching was primarily paternalis-
tic in nature with the teacher serving as the foundation and relaying information to learners. With
meaningful learning, the teacher primarily functions as a facilitator, helping learners to experience and
absorb new information. This is accomplished by creating an environment in which learners are en-
couraged as well as permitted to experiment with concepts and act freely. The learner serves as the
foundation in this situation.
Meaningful learning encourages teachers to use tools such as advance organizers to assist in the
process of learning. These tools can be used prior to a learning experience to prepare the learner’s
mind and activate specific prior knowledge that will be needed to understand and interpret the new
information. An example can be a chart, graph, or an experiment.4 This involves active learning tech-
niques, where the tools can stimulate learners to make meaningful connections between preexisting
and new knowledge.5 Advance organizers are capable of serving this function because they are at a
higher level of abstraction or generality than the information that follows, and they are based on what
the learner already knows.5
In relating new information to old, the information is incorporated into a framework that makes sense
of an overall concept. “The interaction of new knowledge with the existing ideas allows, through its
cognitive activity, the learner to develop new meanings, which are unique to them.”6 To achieve this, a
learner must be willing to learn as well. Only then will it be deemed interesting and meaningful so
they can substantiate and understand the information. As new information is cognitively integrated
within a framework of longstanding concepts and information, the learner is more readily able to as-
similate and develop new meaning, while constantly reinforcing it each time it is applied.
Background
Educational psychology, the study of the social, emotional, and cognitive processes that occur in
learners, has come a long way in the past 70 years.1 The development of behaviorism in the 1950s
considered learning in the form of conditioning, with a focus on observable and measurable exter-
nal factors. However, this theory did not account for cognitive processes and the internal factors in-
fluencing the learner. This led to a shift in education theory towards a focus on cognitive processes
and constructivist ideas. David Ausubel, an American psychologist, contributed greatly to this field
by developing one of the most profound educational theories, Meaningful Learning Theory, first
published in 1963.2
Ausubel advocated that the most important factor in learning is that which the learner already
knows. “Meaningful learning occurs when the learner interprets, relates, and incorporates new in-
formation with existing knowledge and applies the new information to solve novel problems”.3 Ex-
ternal factors, such as one’s learning environment, were still considered significant, but the empha-
sis was primarily on internal factors and the individual learner. Previously, classroom teaching was
primarily paternalistic in nature with the teacher serving as the foundation and relaying informa-
tion to learners. With meaningful learning, the teacher primarily functions as a facilitator, helping
learners to experience and absorb new information. This is accomplished by creating an environ-
ment in which learners are encouraged as well as permitted to experiment with concepts and act
freely. The learner serves as the foundation in this situation.
Meaningful learning encourages teachers to use tools such as advance organizers to assist in the
process of learning. These tools can be used prior to a learning experience to prepare the learner’s
mind and activate specific prior knowledge that will be needed to understand and interpret the new
information. An example can be a chart, graph, or an experiment.4 This involves active learning
techniques, where the tools can stimulate learners to make meaningful connections between preex-
isting and new knowledge.5 Advance organizers are capable of serving this function because they
are at a higher level of abstraction or generality than the information that follows, and they are
based on what the learner already knows.5
In relating new information to old, the information is incorporated into a framework that makes
sense of an overall concept. “The interaction of new knowledge with the existing ideas allows,
through its cognitive activity, the learner to develop new meanings, which are unique to them.”6 To
achieve this, a learner must be willing to learn as well. Only then will it be deemed interesting and
meaningful so they can substantiate and understand the information. As new information is cogni-
tively integrated within a framework of longstanding concepts and information, the learner is more
readily able to assimilate and develop new meaning, while constantly reinforcing it each time it is
applied.
Modern takes on this Theory
In its original presentation, Ausubel’s Meaningful Learning Theory focused on the acquisition and
retention of verbal knowledge in classroom settings where groups of young learners were presented
with subject-specific information by teachers.2 Over the years, this theory has increasingly impacted
62
learners of different ages in various learning environments. In his second monograph, Ausubel
underlined that “the acquisition and retention of knowledge are [not] necessarily restricted to the
formal instructional contexts of schools and universities, where designated teachers and pupils
interact in stereotypical ways mostly for this purpose.”8 Actually, the acquisition and retention of
knowledge are pervasive and lifelong activities essential for the competent performance, efficient
management, and improvement of daily work tasks”.8
Ausubel also noted that the “promise of the cognitive approach to school (subject-matter) learning
and to the acquisition, retention, and organization of knowledge in the learner's cognitive structure
has been amply fulfilled since the publication of ‘The Psychology of Meaningful Verbal Learning’ in
1963.”8 However, the effects of meaningful learning and its application to instructional methods still
remained to be investigated at higher levels of education.
As changes from passive and teacher-centered learning in large classrooms to active and student-
centered learning in small groups have been increasingly adopted, the principles of the Meaningful
Learning Theory have provided the foundation for new instructional methods. The emphasis on
subsumption of new knowledge into the learner’s existing cognitive structure brings the focus on
individual learners, emphasized in the self-directed learning modalities. The requirement for the
learner to process the acquisition of new knowledge engages active learning, which is a prerequisite
of adult learning theories. The achievement of meaningful learning ensures that the educational ex-
perience has practical applications for the learner and promotes their personal growth, which is the
basis for goal-directed and competency-based learning.
In recent years, an effective strategy to achieve meaningful learning has emerged with the use of
concept mapping.7 Concept maps are visual constructs of interconnected elements (concepts) that re-
sult from the processing of instructional material and relevant ideas by the learner. Concept mapping
reflects the learner's cognitive structure assimilating new knowledge. Studies support the effective
application of concept maps in medical student learning.
Gonzalez et al.3 had students learn a cardiovascular module of a medical physiology course by con-
structing concept maps related to cardiovascular physiology. The learning was supported by ‘media-
tors’ (i.e., faculty who assisted students with the cognitive process rather than with subject content).
These students performed significantly better on problemOther Examples of Where this Theory
Might Apply
Other examples of where this theory might apply in both the classroom &
clinical setting
Meaningful learning trains the learner to actively find ways to connect the new information gained
from experience to current knowledge, thereby reorganizing and expanding the learner’s knowledge
and skills. This educational approach is currently being utilized in many medical education pro-
grams to integrate basic and clinical sciences, to develop clinical reasoning, and to promote interpro-
fessional learning. One example includes the integration of basic and clinical sciences by promoting
63
the collaboration of first- and fourth-year medical students during clinical grand rounds presentations,
with a faculty member guiding them through concept maps.10 In this interesting application of the
Meaningful Learning Theory, the advanced modifiers initially laid down by the faculty facilitator were
adapted during the discussion towards the cognitive constructs of the students who explicitly guided
the refinement and completion of the concept maps. Focus groups revealed that students appreciated the
integrated learning of basic science and clinical medicine concepts, as well as the clinical reasoning
thought processes.
In a methodological study on the construction and validation of an American Heart Association Basic
Life Support course for distance learning, the authors provided a concrete example of direct application
of Ausubel’s theory for health professional education.11 Using Bloom’s taxonomy, cognitive educational
objectives were defined, as per American Heart Association recommendations, to guide the course mate-
rial development, the teaching-learning process, and the assessment. Three conditions of Ausubel’s the-
ory were built into the course to enable meaningful learning: (1) to tap into pre-existing knowledge of
the learner, cases that the learners were familiar with were proposed; (2) to ensure the explicit predispo-
sition of the learners to learn, objectives were targeted to the needs of the learners; and (3) to supply new
and structured knowledge, content material was presented in a systematic and logical sequence.
Limitations of this Theory
Central to Ausubel’s theory is the idea that selective anchoring of new material to existing cognitive
structures is necessary for meaningful learning to occur. Yet the conditions that govern this selective an-
choring also exposes inherent limitations to Ausubel’s theory. Specifically, Ausubel’s assertion that
meaningful learning can only occur when a learner is conscientiously willing to learn highlights limita-
tions that may arise when the intention and goals of the learner and teacher are not congruent with
meaningful learning. For example, if the learner simply wants to store content for an upcoming exami-
nation, learning becomes mechanical instead of meaningful. Similarly, if the goal of the learner or
teacher is to do well on an examination that rewards rote memorization, it may be more advantageous to
the learner to justify mechanical learning in the short term.
Another limitation arises from the need for content to be meaningful from a psychological perspective to
the learner. Each learner encompasses a unique outlook and has varied experiences that constitute their
cognitive structure. Thus, if a learner cannot perceive or integrate the content being presented into their
cognitive structure, teaching may become meaningless.
Lastly, Ausubel’s theory necessitates that ample time be available to allow for anchoring and reinforce-
ment of content. Depending on the educational system or constraints upon an individual and the
teacher, the lack of ample time may steer the learner to mechanical learning instead of meaningful learn-
ing.
64
Returning to the case...
A few days later, John is on shift again with Dr. Smith. Dr. Smith comes over and asks, “Hi John, did that review
article on cardiogenic shock help you to better understand the patient we saw together?”
John admits that the review article was very complicated, and he was unable to understand it.
Dr. Smith nods and gestures for John to sit. “I’ve been thinking more about the patient we saw together and how to
better teach you about cardiogenic shock.”
Dr. Smith asks John about his background and any previous jobs he had held. John says that his family owns a
plumbing business and he helped with jobs growing up. Dr. Smith says she wants to use John’s plumbing back-
ground to try and explain cardiogenic shock and the patient’s presentation to John (condition 1: material has sig-
nificance to the learner).
John remarks that he knows about different plumbing systems, pumps, tanks, and pipes (condition 2: learner pos-
sesses relevant cognitive structures to anchor new information).
John is excited and highly motivated to prove to Dr. Smith that he can grasp this material (condition 3: intrinsic
motivation for meaningful learning).
Dr. Smith begins by searching the internet for visual representations of different plumbing systems that utilize
pumps, tanks, and pipes and shows this to John (graphical advance organizer). She remarks that she wants to use
John’s knowledge of plumbing systems to teach him about the patient they encountered (comparative advance or-
ganizer).
Dr. Smith tells John that there are systems of pumps, tanks, and pipes in our body just as there are in the field of
plumbing (derivative subsumption). John knows the concepts of pumps, tanks, and pipes and now considers how
these are also present in the human body.
Dr. Smith then discusses how the body’s pump, tank, and pipes move blood similar to how sewage and water are
moved through pipes (correlative subsumption). John realizes that he must alter his concept of pumps, tanks, and
pipes as they relate to plumbing to now include the possibility of blood flowing through them.
Dr. Smith tells John to think of the body’s system of pipes, tank, and pump as interconnected and states that this is
how the circulatory system of the body works. She tells John that the tank represents the inferior vena cava bring-
ing blood to the pump, which is represented by the heart. And lastly, John is told that the heart pumps blood
through the pipes which can be thought of as the aorta and arteries of the body (superordinate learning). Although
John has a working knowledge of plumbing and different pumps, tanks, and pipes, he is now able to grasp the con-
cept of circulation through his previous experience.
Lastly, Dr. Smith tells John that, similar to plumbing, the body’s pipes can become clogged from different materials.
Dr. Smith relates to John the concept of atherosclerosis and plaque rupture.
65
66
ANNOTATED BIBLIOGRAPHY
1. Ausubel DP. The use of advance organizers in the learning and retention of meaningful verbal
material. J Educ Psychol. 1960;51:267-272.5
This seminal work introduced Ausubel’s idea that learning of unfamiliar but meaningful content can
be aided using “advance organizers” as a tool. It is hypothesized that the use of “advance organizers”
will trigger pre-existing superordinate concepts that have been previously entrenched in a learner’s
cognitive framework to cultivate meaningful learning. Additionally, advance organizers serve as a
tool to provide context and an organized overview of the information to be integrated utilizing
known concepts.
2. Ausubel, D. The psychology of meaningful verbal learning. New York: Grune & Stratton; 1963.2
Ausubel first introduced his Meaningful Learning Theory in 1962, but fully elaborated his theory in
this seminal work. He defined and emphasized meaningful learning and laid out the conditions that
need to be met for meaningful learning to occur. Ausubel makes a distinction between rote learning
and meaningful learning. He describes rote learning as arbitrary and non-substantively incorporated
knowledge which is inefficiently integrated into a learner’s cognitive structure. He contrasts this with
meaningful learning, which he describes as conscientiously integrated knowledge building upon the
learner’s pre-existing cognitive structure in a non-arbitrary, non-verbatim fashion. He outlines that
for this meaningful learning to occur, the material must have potential meaning or significance to the
learner. Additionally, the learner must possess relevant previously acquired concepts to anchor and
integrate the incoming knowledge. Lastly, the learner needs to conscientiously link the incoming
knowledge to their cognitive structure and have intrinsic motivation in order to meaningfully learn.
3. Ausubel DP. Educational psychology: a cognitive view, Ausubel DP. Holt, Rinehart, and Win-
ston, New York; 1968.13
In this work, Ausubel further refines and outlines his Meaningful Learning Theory. This narrative
goes over a detailed description of the various components of his theory in chapters 2 and 3. Ausubel
outlines the importance of the learner’s cognitive structure as a critical factor influencing learning.
Additionally, the ideas behind meaningful reception of information, subsumption of knowledge, and
advanced organizers are further elucidated. Ausubel particularly defines and illustrates four process-
es in these chapters. He outlines derivative subsumption, correlative subsumption, superordinate
learning, as well as combinatorial learning, and their role in meaningful learning.
4. Novak JD. Meaningful learning: The essential factor for conceptual change in limited or inap-
propriate propositional hierarchies leading to empowerment of learners. Sci Educ.
2002;86:548-571.12
The heuristic devices of concept mapping and vee-mapping built upon and helped to translate
Ausubel’s theory into practical use. Concept mapping allows for a visual representation of the cogni-
tive structure through its components of concepts, relationships, hierarchy, and cross-links.
References
1. Bailey JH, Rutledge B. The educational psychology of clinical training. Am J Med Sci.
2017;353(2):96-100.
2. Ausubel DP. The psychology of meaningful verbal learning. New York: Grune & Stratton; 1963.
3. Gonzalez HL, Palencia AP, Umana LA, et al. Mediated learning experience and concept maps: a ped-
agogical tool for achieving meaningful learning in medical physiology students. Adv Physiol Educ.
2008;32:312-316.
4. Getha-Eby TJ, Beery T, Xu Y, O’Brien BA. Meaningful learning: Theoretical support for concept-based
teaching. J Nurs Educ. 2014;53(9):494-500.
5. Ausubel DP. The use of advance organizers in the learning and retention of meaningful verbal mater-
ial. J Educ Psychol. 1960;51:267-272.
6. Sousa ATO, Formiga NS, Oliveira SHS, et al. Using the theory of meaningful learning in nursing edu-
cation. Rev Bras Enferm. 2015;68(4):626-635.
7. Novak JD, Gowin DB. Learning How to Learn. Cambridge University Press; 1984.
8. Ausubel DP. The Acquisition and Retention of Knowledge – A Cognitive View. Springer Netherlands;
2000.
9. Tian Z, Zhang K, Zhang T, et al.. Application of Ausubel cognitive assimilation theory in teaching/
learning medical biochemistry and molecular biology. Biochem Mol Biol Educ. 2020;48(3):202-219.
10.Richards J, Schwartzstein R, Irish J, et al. Clinical physiology grand rounds. Clin Teach. 2013;10:88-93.
11.Costa IKF, Tibúrcio MP, Melo GSM, et al. Construction and validation of a distance Basic Life Support
Course. Rev Bras Enferm. 2018;71(suppl 6):2698-2705.
12.Novak JD. Meaningful learning: The essential factor for conceptual change in limited or inappropri-
ate propositional hierarchies leading to empowerment of learners. Sci Educ. 2002;86:548-571.
13.Ausubel DP. Educational psychology: a cognitive view, Ausubel DP. Holt, Rinehart, and Winston,
New York; 1968.
67
A Case
Julia is a resident in Internal Medicine covering the clinical teaching unit in July of her first year.
After a busy Monday night on-call covering the inpatient teams, she was happy when she looked back and realized
that she was able to problem-solve and appropriately treat various patients who needed attention. She was especially
glad that she effectively arranged the transfer of a patient with COPD to the Intensive Care Unit (ICU), and suc-
cessfully talked one patient out of leaving against medical advice (AMA), in addition to dealing with all of the other
calls and pages overnight.
She met the daytime team on Tuesday morning and gave her signout to the senior resident, Lisa, listing the main is-
sues that came up. Remembering the final months of medical school when a highly-respected ICU attending gave a
mandatory lecture on the key components of a handing over patients during sign out, Julia focused on trying to give
the oncoming resident a good transition of care.
On Wednesday, Lisa ran into Julia after a lecture and mentioned that, on Tuesday morning, the daytime team was
unable to send Mrs. Smith, a woman with newly diagnosed metastatic breast cancer, for her planned interventional
radiology procedure. Julia had started the patient on heparin therapy overnight for a new pulmonary embolism and
had not informed the day-team. Julia remembered the case, and was horrified to realize that she had forgotten to
communicate this in the sign out.
Though Lisa provided this feedback in a very kind senior-to-junior resident teaching manner, Julia felt that she had
let down the day-team by neglecting to convey this particularly important detail during the transition of care. As she
reflected on the sign out list, she recalled feeling overwhelmed with all of the issues that had occurred during her
shift, including the ICU transfer and the patient who was going to leave AMA.
In October of the same academic year, Julia was scheduled to begin an 8-week rotation in the ICU as a junior resi-
dent. Not only was she very nervous to begin a rotation where she would be responsible for making multiple critical
decisions on shift, but she was also more afraid that she would make another error during the handoff and that a pa-
tient would have a poor outcome caused by her oversight. Over the past few months, she had independently re-
searched transition of care and tried different techniques, but she still felt unprepared as October loomed closer.
68
CHAPTER 10
Authors: Tabitha Ford, MD; Mala Joneja, MEd, MD; Anna Bona, MD
Editor: Sreeja Natesan, MD
Sociocultural Theory
69
OVERVIEW
Sociocultural learning theory (SCT) is based upon the concept that learners initially develop new
knowledge and skills by observing and interacting with others in their environment. It highlights the
importance of social interactions for all learners, from children to medical residents. For example,
children are only able to master a new capability after watching their caregivers perform the task.
Similarly, medical residents develop over time the ability to efficiently and effectively communicate
the details of a patient’s condition to others through observation and practice. This is refined only after
several years of hearing details discussed in the language of clinicians, witnessing their preceptors
conducting similar tasks, and being immersed in the social norms of the medical field.
The primary components of sociocultural learning theory are:
●Social influence precedes individual development:1: Before a learner can adopt and understand
a new practice or notion, they must first witness the behavior being performed by another or be
engaged in an environment that promotes the understanding of a novel concept.
●Psychological tools are important for the expansion of knowledge:1: Language is considered to
be the primary psychological tool used by humans to promote learner development.
●The sweet spot for learning is the Zone of Proximal Development (ZPD):1 In this area, learners
are pushed to develop their proficiency by undertaking tasks that would be too difficult alone,
but are possible with the help and guidance of another.
●A “more knowledgeable other” is necessary for the ideal transfer of knowledge:1 In the ZPD,
students need to have another person present, an instructor, who is familiar with the topic, and
can assist the learner when they get stuck.
●Learner support is maintained by a concept called scaffolding:1 Just as a scaffold is used to de-
liver materials and workers to required areas in a building under construction, learners need
someone to support their growth and provide necessary tools for their development.
There are multiple definitions to remember when striving to understand sociocultural learning theory.
Here is a quick glossary for your reference as you continue reading:
●ZPD (Zone of Proximal development): tasks or ideas that a learner may master with the as-
sistance of another, but are too difficult to grasp alone
●MKO (More Knowledgeable Other): a peer or teacher who is more adapt in a particular topic or
skill and may help the learner progress
●Scaffolding: supporting a learner’s development through the use of demonstration, tips, guid-
ance, or other educational tools
●CoP (Community of Practice): a group of people working together to reach a common goal and
learning together through their efforts
MAIN ORIGINATORS OF THE THEORY
Lev Vygotsky
Other important authors or works:
Jerome Bruner
Jean Lave & Etienne Wenger
Background
The person credited with the establishment of sociocultural learning theory is Russian psychologist, Lev
Vygotsky, in the 1920s. This theory was contrary to the popular views of the time that centered around
the concept of knowledge acquisition primarily depending upon the individual traits of a learner.1 Vy-
gotsky is most well known for his descriptions of the ZPD and the importance of a “more knowledge-
able other” in a child’s advancement. In addition to being known for establishing sociocultural learning
theory, Vygotsky also made significant contributions to educators’ understanding of the impact of lan-
guage on learning.1-2
After Vygotsky’s untimely death from tuberculosis in 1934, there was a long period of time in which his
work was not widely known and was heavily edited due to barriers of language and political
discourse.1,3
In 1976, Jerome Bruner and his colleagues expanded on Vygotsky’s theory by describing scaffolding, a
term used to characterize the aid a “more knowledgeable other” contributes to the development of
learners, by supporting students until they are ready to work on their own.4-5 Scaffolding has been ap-
plied to adult learning theory in many fields, and more recently, some have proposed the usage of tech-
nological tools to perform scaffolding functions.5
In the 1990s, Lave and Wenger worked to describe Situated Learning Theory (SLT) in which learners
progress through legitimate peripheral participation in a community of practice (CoP).6 A CoP is an en-
vironment in which multiple participants work towards a common goal by sharing information and
learning from each other as they interact.7 Novice learners are typically included at the periphery of a
CoP through intentional involvement with the guidance of central, more experienced participants,
gradually increasing their level of participation as they gain comprehension and familiarity. Today, a
community of practice may be utilized in the workplace, in the classroom through team-based learning,
or in an online setting to further knowledge acquisition and productivity.6-8
70
Despite the increasing presence in literature describing sociocultural learning theory in education over
the past 30 years, medical educators have tended to focus on learners as individuals and did not strong-
ly consider the effects of the learning environment and social interactions on medical trainees. However,
more recently, instructors in the field of medical education have begun to realize the importance of team
dynamics and interprofessional development in the learner experience and have started integrating
these theories into their practice.9-11
Modern takes on this Theory
Modern takes on Sociocultural Learning Theory include Cultural-Historical Activity Theory in simula-
tion education and the incorporation of the Zone of Proximal Development in surgical education.
Cultural-Historical Activity Theory provides a framework to evaluate simulation training by analyzing
learners’ relationships and the connections between thoughts and emotions related to their actions.12
Key points Yrjö Engeström emphasizes in this theory are that:
1) learning is accomplished as a group working towards a common goal,
2) context has many elements of influence, and
3) that measured outcomes have multifaceted perspectives.2
Simulation is a social activity, and incorporates a group of learners, which differs from the longstanding
individualized theories typically applied in medical education.10 The use of simulation education has in-
creased over the past