Workplace Learning and the Applicability of Cognitive Apprenticeship Model in Internal Medicine Ward Rounds Dr Muhammad Tariq, FRCP (Lon.) FRCP (Edin.), FACP, FAIMER Fellow Section Head, Internal Medicine Associate Professor & Director Postgraduate Programs

Introduction Workplace provides context for learning. In a workplace learner, learn by observing as well as by active participation. It’s an experiential learning where supervised or semi-supervised application of the knowledge occurs.

Introduction Most workplace learning is informal and occurs as a by-product of engaging in work processes and activities. Newcomers often have to learn “How we do things here” without being given any specific objectives or advice. Thus a learning goal might be described by a vague phrase like “being able to do what X does”.

Introduction As per Professor Eraut from UK (2009) the key variables of performance in the workplace are; the context in which the performance is effective, the condition in which competence can be achieved the capability of the performer to handle situations

Theories of Workplace Learning Theories of workplace learning have evolved over the past two to three decades Changing focus from formal to both formal and informal learning Organizational, group and individual learning (Hager, 2011)

Workplace learning Theories Learning as a product; learners acquiring novel attributes Learning as a process; learners developing by actively engaging in the processes of workplaces. Roughly classified learning as product learning as process. Metaphors of learning by Sfard (1998) acquisition participation Learning as product corresponds with the acquisition metaphor, while learning as process accords with the participation metaphor.

Paradigm of Learning Just as education is a socially constructed process, likewise learning theories change according to dominant social ideas [Janet Grant, 1999]

Learning from Experience The process of getting to know work at the workplace is well captured by progression model developed by the Dreyfus brothers (a philosopher and a computer scientist) Dreyfus & Dreyfus, 1986; first to emphasize informal learning from experience and the acquisition of tacit knowledge

Summary of Dreyfus Model of Progression (Dreyfus and Dreyfus, 1986)

Progression at Workplace Doing things better Doing things differently Doing different things

Situated Learning In clinical practice, “situated learning” takes place, where students learn by performing tasks and solving problems in a setting or environment, in which they apply their knowledge and skills (Stalmeijer, Dolmans, Wolfhagen, & Scherpbier, 2009). Situated learning augments transfer of knowledge to new situations as a result of highly meaningful situated cognition associated with it (Brown, Collins, & Duguid, 1989)

Learning in Clinical Practice The traditional model apprenticeship, where students learn by observing clinical practitioners and are given graded tasks to perform as they become more competent (Stalmeijer, et al., 2009). Collins et al. (1989) introduced “cognitive apprenticeship” as an instructional model for situated learning

Cognitive Apprenticeship Principle Dimensions Methods Content Cognitive Apprenticeship Sequencing Sociology

Collin’s Cognitive Apprenticeship Model The model focuses on the four principal dimensions of cognitive apprenticeship: Content Methods Sequencing Sociology The content dimension of cognitive apprenticeship requires the type of knowledge for expertise as domain knowledge and strategic knowledge and the later is further subdivided into heuristic, control or meta-cognitive and learning strategies.

Collin’s Cognitive Apprenticeship Model Cognitive apprenticeship provides Sequencing of learning activities, which includes; increasing complexity, increasing diversity and global to local skills. Collins fourth dimension is Sociology; social characteristics of learning environment, which are situated learning in which students learn in the context of working on realistic tasks, development of communities of practice, intrinsic motivation and cooperation

Collin’s Cognitive Apprenticeship Model Six Teaching Methods are proposed: Modeling Coaching Scaffolding Articulation Reflection Exploration

Collin’s Cognitive Apprenticeship Model Modeling : teachers actively demonstrate and explain skills and procedures to their students. Coaching: teachers observing students and providing specific and concrete feedback on their performance. Scaffolding: support from teachers tailored to students’ individual knowledge levels. As students become more competent support can be gradually reduced and finally withdrawn (fading). Articulation: involves teachers questioning students and stimulating them to ask questions. Reflection: involves ways of stimulating students to deliberately consider their strengths and weaknesses. Exploration: is aimed at encouraging students to formulate and pursue personal learning goals.

Ward Rounds and Cognitive Apprenticeship The cognitive apprenticeship model is highly specific and it is believed that it can enhance learning in clinical practice and in the internal medicine ward rounds. Currently there is sparse data available on application of cognitive apprenticeship model in clinical setting particularly with respect to learning in the ward rounds, which is the mainstay of clinical teaching especially in internal medicine.

Ward Rounds and Cognitive Apprenticeship I will now analyze the teaching and learning in internal medicine ward rounds with respect to the application of Collin’s cognitive apprenticeship model The Analysis is based on our previous study on Ward rounds, literature review and experience

Learning themes in Ward Rounds The following learning themes in ward rounds are identified upon which I will analyze; Clinical presentation skills Clinical problem solving ability and approach towards the patients Clinical skills & Diagnostic competence Management of the patient Communication skills, counseling & professionalism Managerial & leadership skills

1. Clinical presentation skills Clinical presentation skills is learnt & taught by coaching method of cognitive apprenticeship model where teacher observe and provides specific and concrete feedback on the performance of the trainees. In addition medical students and junior residents learn clinical presentation skills by observing their senior residents that how they are presentation the cases. therefore modeling also plays a role.

1. Clinical presentation skills The learners can reflect upon their own presentation and compare with that of the others to learn as well. Here the learning depends upon the encouragement by teacher as well as on self motivation.

2. Clinical problem solving ability and approach towards the patients Scaffolding plays a significant role in imparting clinical problem solving ability and approach towards the patients in medical students and the residents. The teacher supports the trainees and gradually reduces the support as the student/resident become more competent. In addition coaching, modeling & reflection methods also helps learn this theme of learning.

2. Clinical problem solving ability and approach towards the patients I also feel that articulation, where teacher encourage the students to verbalize their knowledge and thinking process improves the approach towards the patient. Moreover increasing complexity & diversity of cases as the trainee become more senior especially with respect to residency, improves the clinical problem solving ability. However domain knowledge is of utmost importance

3. Clinical skills & Diagnostic competence Clinical skills & Diagnostic competence is learnt through modeling, coaching & scaffolding. In order to achieve diagnostic competence domain knowledge need to be adequate and heuristics are sometimes helpful with knowledge of certain disease patterns and illness scripts. Articulation, reflection and exploration improve diagnostic competence.

3. Clinical skills & Diagnostic competence The students/ residents during the rounds come across various problems and the teacher asks questions and encourages students to explore further to be discussed the next day. Exploration invites students to formulate learning objectives and pursue them. Again increasing exposure to complexity & diversity of the cases improves diagnostic competence.

4. Management of the patient Management of the patient is learnt through; modeling, where students/residents learn from their teacher how he is managing the patient, coaching, where teacher teaches the trainee how to manage, scaffolding, where teacher provide graded support and as they become competent gradually support fades. Reflection upon one’s own strengths and weaknesses also helps improves management of the patients.

4. Management of the patient Moreover with experience after seeing a wide range of clinical problems of varying diversity and complexity the theme of learning of management of patients improves. Intrinsic motivation and cooperation also plays a significant role. Service/teaching balance could be maintained with the application of this learning model.

5. Communication skills, counseling & professionalism Communication skills, counseling & professionalism is best learnt through role modeling by the teacher. It’s very important that students/residents observe the faculty, how he/she is communicating with the patients and their relatives, what setting and environment is used, how he reacts to the bad attitude of the patients or the relative, how he/she counsels and break the bad news.

6. Managerial & leadership skills Graded responsibility improves leadership skills. Working in a team with cooperation, where senior resident is responsible for the group dynamics improves the managerial skills and leadership skills. Modeling & scaffolding helps improve leadership skills.

Inference With this analysis we have observed the practicality of cognitive apprenticeship model of situated learning proposed by Collins et al., (1989) in clinical setting The balance between teaching & service can be achieved by applying the model in teaching and conduct of ward rounds More Empiric Data is required to substantiate the findings

Research Proposal . In order to gather more empirical evidence , we plan to conduct a study Collins Model of Cognitive Apprenticeship: A Structure for Teaching and Learning in Internal Medicine Ward Rounds. Muhammad Tariq (Submitted to ERC)

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