1. How Adults Learn Peter J. Fabri, M.D. Professor of Surgery Associate Dean of Graduate Medical Education University of South Florida Health Sciences Center

2. Organic Chemistry 1966  I couldn’t understand it  So I memorized it  Every night I would rewrite my lecture notes from the beginning of the semester  It went this way for 4 months  One morning it made sense and from that day on I could learn

3. Childhood Learning  Rote memory  Repetition  Testing as feedback  Gathering building blocks  Vertical and additive?

4. Adult Learning  Conceptual  Contextual  Continuous  Horizontal and integrated?

5. Learning Theories  Many talented educators have developed theories to explain the processes of the human mind.  Are they correct? Maybe in part.  Then why use them?  Because they provide a structure that helps us understand how to teach and glues together the episodes of learning.

6. Four Learning Theories  Bloom’s Taxonomy  Gardner’s Theory of Multiple Intelligences  Gagne’s Theory of Conditions of Learning  Dreyfus Process of Learning

7. Why is medical education different now?  How much to learn? – Until recently, the amount of relevant clinical knowledge was finite and knowable. – The rate of knowledge expansion is now exponential.  Where do we learn? – The traditional teaching ward provided opportunity for continuity, integration, and interaction. – The modern teaching clinic is fragmented, episodic, and discontinuous.

8.  In the past, core knowledge could be learned in medical school.  An intern or resident was an apprentice, mastering a set of skills.  Once learned, the knowledge was thought to suffice for life.  Today, medical education is a continuous, lifetime commitment to learning while working Why is medical education different now?

9.  In the past, the physician was the unchallenged captain of the team. –led by authority –individual superstar with a team of helpers –learned in elite isolation  Today, the physician is a senior member of a multidisciplinary team. –leads by example –one of many talented team members –learns in an integrated and interrelated system Why is medical education different now?

10. Learning on the Wards  The Osler model  Large wards; long hospitalizations  All diseases are likely to be represented in all phases.  Under the direction of a master, an individual is able to observe the full spectrum of a disease and its treatment.

11. Learning in the Clinic  Fragmented and episodic  Never see the whole picture  Little continuity  Requires an educational model to “glue” the pieces together

12. Modern “Tools”  Competency-based education  Lifelong learning  Continuous improvement  Evidence-based Medicine  Clinical guidelines  Maintenance of competence

13. Coaches vs. Teachers  A teacher is an individual who tells the students what, when and how to learn, then tests to see if they have learned.  A coach provides context, direction, motivation, and leadership, evaluating progress along the way.

14. Cognitive Domain- Knowledge Bloom’s Taxonomy knowledge comprehension application analysis synthesis evaluation

15. Psychomotor Domain- Skills Bloom’s Taxonomy observing preparing performing/aided acting facility

16. Affective Domain- Attitudes Bloom’s Taxonomy paying attention participating valuing value system adopting outlook

17. Multiple Intelligences  Learning is composed of multiple sensory and intellectual inputs --sound, sight, smell, etc.  The greater the number of inputs attached to a particular idea, the greater the retention of the information.  Some individuals learn better orally, some visually, some kinesthetically, some by combinations.

18. 8 Multiple Intelligences  Linguistic (word smart)  Logical-mathematical (number smart)  Spatial (picture smart)  Kinesthetic (body smart)  Musical (music smart)  Interpersonal (people smart)  Intrapersonal (self smart)  Naturalistic (nature smart)

19. Gagne- Conditions of Learning  There are several types or levels of learning.  Each type requires a different type of instruction, and has different conditions.  Five major categories of learning: – verbal, intellectual skills, cognitive strategies, motor skills, attitudes  Prerequisites to learning for each level

20. Gagne- 9 instructional events  gaining attention (reception)  informing re objectives (expectancy)  recalling prior learning (retrieval)  presenting stimulus (selective perception)  providing guidance (semantic encoding)  eliciting performance (responding)  providing feedback (reinforcement)  assessing performance (retrieval)  enhancing retention and transfer (generalization)

21. Gagne- Principles  Different instruction is required for different learning outcomes  Events of learning operate on the learner in ways that constitute conditions of learning  The specific operations that constitute instruction are different for each type  Learning hierarchies define what intellectual skills are to be learned and a sequence of instruction

22. Skill Acquisition Dreyfus model (1980)  novice  advanced beginner  competent  proficient  expert  master é3rd year student égraduating student échief resident éboard eligible (+2years) é5-10 years practice é?

23. Common Misbeliefs  Everyone wants to learn  Everyone learns the same way  Everyone learns at the same rate  Once learned, knowledge is forever  Memorized information can be used  Everyone can integrate knowledge

24. Summary  The “apprenticeship” model is rapidly being replaced by adult learning – Competency based – Objectives driven – Consistent evaluation methods

25. Summary 2  Different learners require different learning methods and assistance  Learning is hierarchical and increases in complexity and interrelatedness  Learning requires prerequisite knowledge and/or experience  Varied learning opportunities and experiences enhance retention  Something learned may not be able to be used!

26. Conclusion  If you want to be involved in adult learning, you need to try to understand the intricacies of adult learning.  The traditional notion that everyone learns at the same speed, in the same way, with the same outcome must be reassessed and methodologies modified.