Thursday, April 18, 2013
Lifelong learning and teaching in medicine
"It gave a tremendous level of self-confidence, that through exploration and learning one could understand seemingly very complex things in one's environment."
In medicine, we knowingly commit ourselves to lifelong learning. Very early in our medical education, most of us are told that some portion of what we are taught will be found to be incorrect (or at least will be updated), which requires each of to find ways to keep up with our respective fields. Despite the amount of learning that we do, many of us have little understanding of the actual learning process.
A commonly used phrase in medicine is "see one, do one, teach one," making reference to increasing levels of understanding of the subject matter.
A more formal model to classify levels of learning objectives is Bloom's Taxonomy, which is divided into three types of learning, or domains: cognitive (knowledge), affective (emotional), and psychomotor (physical skills). For the purposes of medical education and this post, our focus is on the cognitive domain.
The cognitive domain is further divided into six increasing levels of learning, which are recognized by goals and objectives that the learner is able to demonstrate at each level. These have been updated since the original publication (the Wikipedia article above shows the old version).
Below is my attempt to give a simple explanation of the current iteration of the cognitive domain of Bloom's modified taxonomy (listed from lowest to highest level of learning).
Knowledge: Lowest level actions such as memorizing, recall of information, and basic concepts. Example: Listing types of inflammatory arthritis.
Comprehension: Understanding of information and meanings as well as context. Example: Understanding that arthritis could be divided into non-inflammatory and inflammatory causes, and further subdividing inflammatory causes into categories such as monoarticular, oligoarticular and polyarticular.
Application: Problem solving and making use of the information. Example: Recognition of a patient with inflammatory polyarthritis and deciding to order RF and CCP as part of the workup.
Analysis: Organization of parts and recognition of patterns. Example: Recognition that a patient with inflammatory polyarthritis has additional features such as rash and nail pitting, suggesting psoriatic arthritis.
Synthesis: Being able to formulate, defend, and argue information. Example: Developing a treatment plan for a patient that has an unclear diagnosis because of overlapping features.
Creation: Being able to assemble, recommend, criticize, support, or discriminate information. Example: Selecting a treatment plan for a patient who has failed standard therapies or has comorbid conditions making treatment decisions difficult.
The differences between levels of learning can be subtle, but by looking at the action verbs used to describe each level from the references above, you should be able to roughly estimate your current level of understanding for a topic.
As an example, most adult rheumatologists should find themselves at the level of creation in terms of management of rheumatoid arthritis, but might only be at the level of knowledge or comprehension for a topic such as the autoinflammatory syndromes (e.g. Familial Mediterranean fever or TRAPS).
Recognizing your current level of understanding is helpful when you want to increase your level of understanding for a topic. For the autoinflammatory syndromes, one might recognize that they are only aware of the names of these syndromes (knowledge level), and increase their learning level by organizing features that differentiate these syndromes into a chart (comprehension level or higher).
As mentioned above with "see one, do one, teach one", an effective way to maximize the learning process is to teach. While some of us are actively teaching residents and fellows to keep us functioning at the higher levels of learning, many do not have this option.
My suggestion would be to set up a simple website or blog (which we discuss in episode 6 of the podcast) to share what you have learned with others. The mental processes involved in organizing information to be shared will further advance your understanding, which can be furthered by ongoing discussions on social media. In my case, being part of discussions on The Rheumatology Podcast and posting on the blog there have undoubtedly increased my learning level for a number of topics.
If you're not ready to make the jump to blogging quite yet, Twitter is an excellent option for sharing short bullet points (for an example of this done extremely well, check out @RheumPearls).
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine. This post originally appeared at his blog.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Suneel Dhand, MD, ACP Member
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.