Lessons in Learning
Before I decided to become a medical educator, I was painfully aware of my medical knowledge gaps. It was terrifying to consider being in charge of educating future medical professionals when there was so much that I did not know. But I took the plunge and accepted a position with the University of Louisville faculty on the vote of confidence of the Department of Family & Geriatric Medicine. Over the ensuing two years, to my surprise, the greatest hindrance to teaching was not actually my medical knowledge gaps. We are all life-long learners for a reason, after all. Rather, the greatest hindrance was my lack of knowledge about learning itself. 
Learning is hard. That may seem like an obvious statement to some, but it was not a concept I had dwelt on in my years as a student. Even if it involved long hours of study, learning material for tests never felt terribly difficult for me. Which led me to the question that has haunted me since I started as an educator: was I actually “learning” in medical school or just passing tests? And the answer to that question holds very significant implications for how we should approach teaching our trainees.
Unfortunately, I have concluded that much of my time in medical school was spent on the latter: just passing tests. The vast amount of material I have forgotten since that time is evidence of such. We also know from research in psychology and education studies that learning requires mental work, and many of the study methods that medical students use to “learn” do not engage them in such effort.1 For example, re-reading material has very little benefit for longer term retention, whereas active recall, such as flashcards and quizzes, are much more beneficial.1 I wish I had known that as a a medical student and focused more on learning for my career, rather than the next grade. Now that I’m an educator, I want to teach my trainees what I did not know about how to learn.
There are many great books on these topics that I would highly recommend to any of you who, for your own learning or your trainees’, want to know more. A few that I have found thoroughly informative include Small Teaching1 , How Learning Works2 , and How We Learn.3
In addition to not knowing how to learn, I had also never considered that there are hierarchical levels to knowledge mastery beyond memorization. I never paid attention to the difference between memorizing a piece of information versus applying a piece of knowledge to a particular patient care scenario. One model for thinking about this is a taxonomy created by Benjamin Bloom (aka, Bloom’s Taxonomy) in the 1950s.4 It has been modified some since his original work,5 but the central concept is that learning does not end with the ability to recite information. Instead, there are additional levels of learning arranged hierarchically. Remembering and understanding are at the lowest levels, but as you “learn” material better you are able to use it for application, evaluation, analysis, etc. In medicine, we need our learners to move past simply remembering and encourage them in application. With this in mind, we can intentionally focus our lessons, bedside questions, and mentoring to prepare trainees for the actual practice of medicine where knowledge is useless unless appropriately applied.
The journey toward the higher levels of knowledge mastery is long and arduous. To this end, there is another pop psychology concept I wish I had learned about earlier in my journey: grit. Grit is a concept developed by Angela Duckworth who has a worth-the-read book of the same title.6 She defines this quality of grit as “passion plus perseverance”. Her research demonstrates that grit can be highly predictive of success in many ways, such as grittier students being more likely to graduate high school.6 In many ways, our profession self-selects for students with both passion and perseverance. But as we move from trainee to professional, the work becomes more difficult, the tasks never-ending and the demands ever increasing. We could all probably benefit from having some additional grit.
Now, knowing about grit is one thing, but how do we become grittier - or help our learners become grittier? Duckworth proposes that we should look to yet another psychology concept for one possible answer: growth mindset. This is a concept from psychologist Carol Dweck that has innumerable applications to our personal approach to medical practice, our professional approach to education, as well as the influence we can have on trainees who need perseverance.7 Dweck describes two different states of mind in her work: a fixed mindset and a growth mindset. A fixed mindset represents a learner who believes that they are innately “good” or “bad” at something, such as math. This attitude is very limiting as a student who believes their potential in a subject is fixed, will likely not spend much more time trying to improve (or persevere). In the opposite way, a student with a growth mindset believes that being good at something is not an innate characteristic, but more a matter of time and effort.7 Rather than being simply “not good” at math, a growth minded individual is “not good at math yet.”
If you are unfamiliar with the concept of a growth mindset, I strongly encourage at least a short dive into Dweck’s work. In the training of residents and medical students, it has become a cornerstone to my approach. They need encouragement to stop seeing every criticism or mistake as a “failure”, which they relate to the bad grades they always had to avoid in years past. Instead, they need to understand that they are in an intense season of learning. They are not ready to be independent doctors, yet. And every mistake, attending’s suggestion, or piece of knowledge relearned are necessary steps in the journey. Perseverance is not as difficult a task if the friction created by a fixed mindset can be relieved with strategically applied grease. We need to give ourselves permission to continue being learners, even as we strive for excellence.
Whether you are a medical educator, occasional preceptor, or spend all of your professional time in direct patient care, there is something here for all of us as life-long learners to learn about learning.
References:
1. Lang JM. Small Teaching: Everyday Lessons from the Science of Learning. San Francisco, CA: Jossey-Bass; 2016.
2. Ambrose SA, Bridges MW, DiPietro M, Lovett MC, Norman MK. How Learning Works: 7 Research-Based Principles for Smart Teaching. San Francisco, CA: Jossey-Bass; 2010.
3. Carey B. How We Learn: The Surprising Truth About When, Where, and Why It Happens. New York, NY: Random House; 2014.
4. Bloom BS, Krathwohl DR, Masia BB. Taxonomy of Educational Objectives: The Classification of Educational Goals. New York, NY: Longman; 1984.
5. Anderson LW, Krathwohl DR, Bloom BS. A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom’s Taxonomy of Educational Objectives. New York, NY: Longman; 2001.
6. Duckworth A. Grit: The Power of Passion and Perseverance. New York, NY: Scribner; 2016.
7. Dweck CS. Mindset: The New Psychology of Success. New York, NY: Random House; 2006.