EdTheoryMadePractical - Volume 1

EDUCATION THEORY 
MADE PRACTICAL VOLUME 1
Chan | Gottlieb | Sherbino | Boysen-Osborn | Papanagnou | Yarris

COPYRIGHT
Education Theory Made Practical: Volume 1  

Published by Academic Life in Emergency Medicine,  
San Francisco, California, USA.
First edition, August 2017.
 
Available for usage under the Creative Commons Attribution-
NonCommercial-NoDerivs 3.0 Unported License.
ISBN: 978-0-9992825-0-2
i
EDUCATION THEORY 
MADE PRACTICAL 
VOLUME 1
Editors
Teresa M. Chan, MD, MHPE 

Michael Gottlieb, MD 
Jonathan Sherbino, MD, MEd 
Megan Boysen-Osborn, MD, MHPE 
Dimitri Papanagnou, MD, EdD(c) 
Lalena Yarris, MD, MCR
Faculty Incubator 
Academic Life in Emergency Medicine 
ii
DEDICATION
Thank you so much to the online communities (#MedEd and #FOAMed)

that have made this happen. We are greatly indebted to the online citizens
who helped to peer review this book and would like to thank them for con-
tributing so openly and freely.
Thank you also to all the participants of the inaugural class of the ALiEM
Faculty Incubator. Your hard work has finally paid off in this book, and we
are so proud of all the work you did for this compendium. We are sure that
the work you have done here will go on to help many other junior clinician
educators in the future. We are so proud of all that you did in 2016-2017
and we look forward to seeing all that you will do going forward!
! ! ! ! - Teresa, Mike, Megan, Jon, Dimitri, Lainie
iii
ABOUT THIS BOOK
About
Education Theories Made Practical (Volume 1) provides a case-based discussion of
core theories in medical education. A collaborative project between the Academic
Life in Emergency Medicine (ALiEM.com) and International Clinician Educators
(ICE) blog, this project is meant to help beginning clinician educators gain a sense of
how education theory can apply to their daily practice.
Each chapter was written, edited, and released on the ICE blog over a four-month
period, where peer-review was sought and subsequently incorporated into this final
version.
Each chapter begins with a common case facing educators, followed by a discussion
of the theory itself and modern applications of the theory, and finally the case is
closed by discussing how the specific theory can be applied to the learner. An anno-
tated bibliography is also included to provide the reader with additional resources
for further learning. Each chapter can be read independently or in series at the
reader’s preference.
Since these materials were originally derived as part of the Free Open Access Medi-
cal Education (FOAM or #FOAMed) movement, we are committed to distributing
this resource as a free ebook.
Purpose
The Education Theories Made Practical ebook is designed to provide an efficient
primer on ten core education theories that can be applied by the reader in a practical
manner, while also providing a resource for identifying further relevant literature.
Usage
This document is licensed for use under the creative commons selected license:
Attribution-NonCommercial-NoDerivs 3.0 Unported.
 
Where can I find this online?
The ALiEM Education Theory Made Practical series can be found online at: 
https://www.aliem.com/education-theory-made-practical-series/
iv
Editors
Teresa M. Chan MD, MHPE 
Michael Gottlieb MD 
Megan Boysen-Osborn, MD, MHPE 
Jonathan Sherbino, MD, MEd 
Dimitri Papanagnou, MD, EdD(c) 
Lalena M. Yarris, MD, MCR
Foreword
Felix Ankel, MD
Chapter Authors
Chapter 1! Modal Model of Memory 
! ! Sylvia Alden, MD; Rachel Dahms, MD; Emily Rose, MD
Chapter 2! Naturalistic Decision Making 

! ! Clare Desmond, MD; Josh Kornegay, MD; Jillian Mongelluzzo, MD
Chapter 3! Communities of Practice 

! ! Andrew King, MD; Michael Abraham, MD, MS; Kevin Scott, MD
Chapter 4! Emotional Intelligence 

! ! Lauren Conlon, MD; Kory London, MD; Michael Pasirstein, MD, MPH
Chapter 5! Social Constructivism 

! ! Eric Cioè Peña, MD, MPH; Abra Fant, MD, MS; Anne Messman, MD
Chapter 6! Reflective Practice 

! ! Jordan Spector, MD; Sara Krzyzaniak, MD; Lauren Wendell, MD
Chapter 7! Self-Directed Learning 

! ! Jenna Fredette, MD; Cathy Grossman, MD, CHSE; Joe Walter MD
Chapter 8! Bloom’s Taxonomy 

! ! Aaron Brown, MD; Nicolas Pineda, MD; Christopher Sampson, MD
Chapter 9! Dual-Process Reasoning 

! ! Antonia Quinn, DO; Daniel Robinson, MD; Adam Tobias, MD, MPH
Chapter 10! Gaming and Gamification 

! ! Will Sanderson, MD, Samantha L. Wood, MD
v
Peer Reviewers
Chapter 1! Modal Model of Memory 
Brendie Hardie, ‘bupward’, John Casey, Tina lani, Rowan Duys, Kate Jurd, Andrew King, Hector Lopez, Gord McInnes, Da-
mian Roland, Christine Savi
Chapter 2! Naturalistic Decision Making 

Esther de Groot, Rowan Duys, Andrw Hughes, Damian Roland
Chapter 3! Communities of Practice 

Rowan Duys, Michelle Lin, Damian Roland
Chapter 4! Emotional Intelligence 

John Casey, Rowan Duys, Damian Roland
Chapter 5! Social Constructivism 

John Casey, Kate Denning, Rowan Duys
Chapter 6! Reflective Practice 

Ian Cox, Jordana Haber, Hector Lopez, Damian Roland
Chapter 7! Self-Directed Learning  

Teresa Chan
Chapter 8! Bloom’s Taxonomy 

‘Dyfrig’, Damian Roland, Andrew Warren
Chapter 9! Dual Process Reasoning 

Teresa Chan, Sandra Monteiro, Jonathan Sherbino, Nick Byrd 
vi
FOREWORD
This is the book I wished I had read at the beginning of my medical education jour-
ney. Like many of my peers, I became involved in medical education because of posi-
tive role models and a desire to contribute back to the field. Most of what we did
was based on historical precedent and influenced by the desires of strong personali-
ties and accreditation and compliance standards. We did not weave solid educa-
tional theory into the programs we built, the decisions we made, or the individual or
programmatic assessments we performed. It was on the job training with many
painful mistakes.
Knowledge of educational theory is foundational to being an effective educator. It

offers a framework to connect the everyday work to a greater context and body of
knowledge. Learning programs based on educational theory allow educators to col-
lect and measure outcomes, confirm or refute commonly held beliefs, and contribute
to scholarship and innovation in medical education.
This book is wonderfully succinct, easy to read, and superbly edited by Teresa Chan,
Michael Gottlieb, Jon Sherbino, Megan Boysen-Osborn, Dimitri Papanagnou, and
Lainie Yarris. Chapters are written by a dynamic community of educators connected
through a faculty development incubator. Each chapter starts with a case descrip-
tion, followed by an overview of the educational theory that is presented, followed
by the case outcome and further references for readers wishing an even more in
depth analysis of the educational theory.
Topics include the theories of modal model of memory, naturalistic decision-making,

communities of practice, emotional intelligence, social constructivism, reflective prac-
tice, Bloom’s taxonomy, and dual process reasoning. Chapters stands on their own
and can be read non-sequentially. Be prepared to learn about the key opinion lead-
ers behind the educational theories, the specific language used with the theories, and
practical examples of how the theories can be applied to practice.
Everyone in medical education should read this book. It is the most efficient use of
time spent learning about educational theory that I am aware of.
Felix Ankel, MD 

Vice President, Health Professions Education, HealthPartners 
Professor of Emergency Medicine 
University of Minnesota Medical School 
vii
CH APT E R 1
Modal Model of Memory

Authors:!Sylvia Alden, MD; Rachel Dahms, MD; Emily Rose, MD 
Editor: " Michael Gottlieb, MD 
A CASE
Joan was a second-year resident with severe test anxiety. She consistently struggled with
passing her examinations in medical school, which frustrated her, as she was always able
to memorize things quickly.
Throughout college and medical school, she would study by cramming for hours the night
before an exam. She often would perform well on small quizzes with this approach, but
always struggled with her final exams. She wanted to remember everything for her
upcoming in-service exam, which she did very poorly on during her first year. She sought
advice to improve her study techniques to facilitate better long-term retention.
Question for the Reader
• For a learner like Joan, what would you suggest as a good way for her to
review the material?
1
OVERVIEW | MODAL MODEL OF MEMORY
The modal model of memory suggests that the human memory has three separate
components:
1. Sensory register: Information initially enters via the five senses

2. Short-term memory (STM): The ‘working memory’ where information from both
the sensory register and long-term memory is processed
3. Long-term memory (LTM): A long-term storage area that holds information that
has been rehearsed in the STM
As the STM has finite capacity and requires significant energy requirements, not all
sensory information is attended to. Therefore, the content of the STM is significantly
smaller than that of the sensory register. The sensory register is the sum of all input,
whereas the STM is what you pay attention to, or consciously think about. The STM
can hold between 5 to 9 discrete pieces of information at a time. There is a constant
transition of items from STM to LTM. Items are moved into LTM based on the amount
of time they are kept in the STM. As new items are introduced into the STM, the
oldest items are lost after the capacity has been reached. If these items have moved
into LTM, they are retrievable. LTM is indefinite, serving as a permanent store of
information. However, if the information has been replaced in the STM before moving
into LTM, these items are lost and not retrievable (i.e. not learned).
The following figure summarizes this model.
 
2
MAIN ORIGINATORS
Richard Atkinson & Richard Shiffrin
•Atkinson RC, Shiffrin RM (1968). “Chapter: Human memory: A proposed system and its
control processes”. In: The psychology of learning and motivation. Spence KW, Spence
JT (eds). New York, NY: Academic Press. 
•Izawa C. (2014) On Human Memory: Evolution, Progress, and Reflections on the 30th
Anniversary of the Atkinson-Shiffrin Model. New York, NY: Psychology Press.
OTHER IMPORTANT RELATED AUTHORS

Alice Healy
•Healy AF, McNamara DS. Verbal learning and memory: does the modal model still
work? Annu Rev Psychol. 1996;47:143-172. 
Alan Baddeley
•Baddeley A. Working Memory. Comptes rendus de l’Academie des sciences. Serie III,
Sciences de la vie.1998;321(2-3):167-73.
•Baddeley A. Working Memory: Theories, Models, and Controversies. Annu Rev
Psychol. 2012; 63(1): 1-29.
BACKGROUND
The earliest reference to modal memory (i.e. the idea that there are separate,
though interconnected, memory stores) was by William James in 1890.1 He de-
scribed primary memory as momentary, conscious memory and secondary mem-
ory as permanent, unconscious memory. The observation that heralded the mod-
ern theory of modal memory was that a short sequence of items will be forgotten
if rehearsal is interrupted by a distraction. Although there were many contempo-
raneous descriptions of this theory of memory, Atkinson and Shiffrin gave the
most complete description in 1968.1-3 They were also the first to add a third as-
pect to this theory: sensory register.
3
MODERN TAKES ON THIS THEORY
One of the most influential models to arise out of the initial Atkinson & Shiffrin
theory is Alan Baddeley’s Working Memory Model.4,5 This model postulates that in-
stead of a single, limited-capacity STM that passively stores information, there is
a multi-component active processing system. This model is composed of a super-
visory system (i.e. central executive system) and two slave systems (i.e. the pho-
nological loop and the visuospatial sketchpad).
The central executive system is in charge of strategy selection and integration

from various sources including the phonological loop and visuospatial sketch-
pad. It is responsible for attentional control. The phonological loop stores infor-
mation with sub-vocal rehearsal (i.e. internal, silent dialogue). If information is
not rehearsed in such a manner, the data will decay within seconds. Inputs into
this loop include both the internal dialogue and external auditory input sur-
rounding an encounter. The visuospatial sketchpad involves both visual and spa-
tial processing that are separate from the verbal processing of the phonological
loop. As an example, when reading a book, one often creates an internal, silent
dialogue (i.e. phonologic loop) while also visually reading the words (i.e. visuo-
spatial sketchpad). This combination of factors can enhance retention by activat-
ing multiple systems, as opposed to one system in isolation.
Another theory derived from the modal model of memory is that of conceptual
short-term memory. Conceptual STM is used for sentence processing, everyday
reading, and scene perception.3,6 It is postulated that when presented with a vis-
ual stimulus, such as a sentence, the information simultaneously goes into the
phonological loop, as well as the conceptual STM. This area of memory can hold
large amounts of information, although it decays very quickly unless it has rele-
vance to an existing conceptual structure that is already organized and stored in
the LTM. For example, when learning about congestive heart failure, a medical
student will better retain new information about the use of nitroglycerin when
linking this to existing knowledge about the Frank-Starling law.
4
Search of associative memory is a theory put forth by Raaijmakers and Shiffrin in
1981 that addresses retrieval from LTM.1,7,8 It is based on the idea that events are
encoded in memory as separate “packages” that can be accessed via retrieval
cues. The strength of the cue will be determined by pre-existing relationships, as
well as rehearsal and coding performed in the STM. In other words, two images
are linked together by rehearsing them in conjunction with each other. Therefore,
recall from the LTM is based on cues originating from the subject, with each cue
assigned different value based upon the degree of salience to the subject. When
retrieval is attempted, memory images with strong retrieval cues will be recalled
more easily than those with weak retrieval cues. For example, dog-cat is easier to
recall than dog-chair.
Finally, Ericsson and Kintsch put forth the idea of long-term working memory in
1993 to explain why working within an area of expertise appears to allow indi-
viduals to far exceed the constraints of working memory.1,9 They proposed that
skilled use of storage in long-term working memory can be combined with tem-
porary storage in short-term working memory. They felt that retrieval cues made
well-known information much faster to retrieve, and allowed active manipula-
tion of this information to supersede the rules of working memory. Specifically,
they suggest that there is minimal effect from interruption; interrupting a reading
test does not dramatically reduce comprehension of the material prior to the inter-
ruption. Building upon the example above, dog-cat has a long history within the
reader’s mind given their association as four-legged house pets. However, dog
and chair are not commonly identified together. Therefore, given equal chances
to memorize both, the former is more easily recalled.
OTHER EXAMPLES OF WHERE THIS THEORY COULD APPLY
The modal model of memory stresses the importance of actively reviewing re-
cently encountered material in order to move it into LTM. Additionally, there is
emphasis on actively moving information from the sensory register into the STM,
which is the first step in storing the information within LTM.
5
In the classroom, there are several different ways to encourage this necessary
repetition. One approach could be the use of planned educational sessions, fol-
lowed by simulation cases based on the topics discussed in order to build repeti-
tion into the structure of the curriculum. There is also some evidence supporting
the flipped classroom. This may improve information retention by requiring
learners to prepare in advance for an in-class session, thereby increasing the time
spent storing and recalling information in LTM.
In the clinical realm, having learners give a short presentation on a clinical entity
that they recently encountered can assist in enhancing retention of the material.
Bridging between the classroom and clinical learning will further assist learners
in encoding information into LTM. This can be done by asking learners what
they have been studying and having them to apply this new information to cur-
rent clinical encounters.
LIMITATIONS OF THIS THEORY
In 1972, Craik and Lockhart noted that the encoding of information from STM to
LTM is not solely dictated by the time spent in rehearsal, but also depends on the
amount and depth of attention. Rehearsal at a shallow level (i.e. Type 1 process-
ing) will result in a higher rate of forgetting than Type 2 processing.1,11 They de-
fined Type 1 processing as repetition without analysis, whereas Type 2 process-
ing consists of deep rehearsal with analysis of the stimulus. As an example, re-
peating “albuterol treats asthma” for three minutes would be considered Type 1
processing, whereas thinking about how albuterol, as a ß-agonist, binds with ß2
receptors in the smooth muscle of the airways and reduces bronchoconstriction
in the lungs, would be considered Type 2 processing.
Additionally, the modal model of memory assumes that all LTM is permanent
and that any perceived loss of information from this store is just a problem with
retrieval.1,12 However, there appears to be some degree of information that is lost
when it is not regularly rehearsed.1,13 Of note, this can be minimized when the
person has expert-level knowledge of the material. For example, the average phy-
sician may not recall much of the Krebs cycle several years after medical school.
6
However, a physician with extensive prior experience in metabolic research,
would be far more likely to retain the same information, even if she did not use it
in her current career.
RETURNING TO THE CASE...

Joan chose to focus her initial efforts on infectious diseases, the material she was least com-
fortable with, and targeted her energy on learning and retaining this material.
She decided to exercise the practice of rehearsal with information. She started with a brief
board review chapter on the topic, worked through some practice cases, and then dove
deeper into a book chapter review of the topic. She assembled notes for herself to review
later using tables and graphs. Subsequently, she reviewed her prior patient visit list for
those with infectious diseases. She reviewed the clinical presentation, the diagnosis, the
pathophysiology, and the management for each patient’s case. Finally, she created quizzes
and consistently exercised retrieval practice to improve her recall during stressful scenar-
ios. She realized that when she returned to the information and reviewed it on subsequent
days, she recalled and understood it much better than with her prior approach of quick
memorization.
Once she had finished a subject, she moved on to another topic, but made sure that she
spent sufficient time delving into each subject, as well as rehearsing material she had pre-
viously mastered to improve her recall. She enjoyed learning with this approach and her
score significantly improved on this year’s in-service exam. She also felt stronger and
more confident with each topic in the clinical arena.
7
ANNOTATED BIBLIOGRAPHY OF OTHER WORKS OF INTEREST
1. Healy AF, McNamara DS. Verbal learning and memory: does the modal model
still work? Annu Rev Psychol. 1996;47:143-172. 
This is a review article that provides a thorough discussion of verbal learning and memory.
It begins with a background of the work leading up to Atkinson and Shiffrin’s modal
model of memory. This is followed by a description of the model itself and discussion of the
research supporting and refuting the model. Finally, the authors discuss extensions and
alternative theories to the model. This article serves as a great starting point for the reader
interested in a more in-depth overview of this model.
2. Baddeley A. Working Memory. Comptes rendus de l’Academie des sciences.

Serie III, Sciences de la vie. 1998;321(2-3):167-73. 
This article discusses one of the most influential theories derived from the original modal
model of memory, the concept of working memory. Working memory is a system for the
temporary storage and manipulation of information. This publication details the history of
the analysis of the functional structure of human memory and the associated controversies.
It presents the background behind the development of the three-component model (i.e. the
central executive system, the visuospatial sketchpad, and phonological loop).
3. Smith AM, Floerke VA, Thomas AK. Retrieval practice protects memory against
acute stress. Science. 2016 Nov;354(6315):1046-8. 
This study compared retrieval practice (RP) with standard study (SS) techniques (i.e.
repeatedly restudying the same material) for recall during stressful scenarios. Participants
were randomized to RP and SS groups and then quizzed 24 hours later in both stressed
and non-stressed environments. The stressed RP group performed similarly to both non-
stressed groups (i.e. RP and SS) and significantly better than the stressed SS group. The
authors suggest that using RP can counteract the decreased memory response noted
during stressful scenarios.
REFERENCES
1. Healy AF, McNamara DS. Verbal learning and memory: does the modal model still work? Annu Rev
Psychol. 1996;47:143-172.
2. Atkinson RC, Shiffrin RM (1968). “Chapter: Human memory: A proposed system and its control proc-
esses”. In: The psychology of learning and motivation. Spence KW, Spence JT (eds). New York, NY:
Academic Press.
3. Izawa C. (2014) On Human Memory: Evolution, Progress, and Reflections on the 30th Anniversary of
the Atkinson-Shiffrin Model. New York, NY: Psychology Press.
4. Baddeley A. Working Memory. Comptes rendus de l’Academie des sciences. Serie III, Sciences de la
vie.1998;321(2-3):167-73.
5. Baddeley A. Working Memory: Theories, Models, and Controversies. Annu Rev Psychol. 2012; 63(1):
1-29.
6. Potter M. Very short-term conceptual memory. Memory & Cognition. 1993; 21(2): 156-161.
7. Raaijmakers J, Shriffin R. Search of associative memory. Psychological Review. 1981; 88(2): 93-134.
8. Raaijmakers J (1993). The story of the two-store model of memory: past criticisms, current status, and
future directions. In: Attention and Performance XIV. Cambridge, MA: MIT Press.
9. Ericsson K, Kintsch W. Long-term working memory. Psychological Review.1995; 102(2): 211-245.
10.Smith AM, Floerke VA, Thomas AK. Retrieval practice protects memory against acute stress. Science.
2016 Nov;354(6315):1046-8.
11.Craik F, Lockhart R. Levels of processing: a framework for memory research. Journal of Verbal Learn-
ing and Verbal Behavior. 1972; 11: 671-684.
12.Bahrick H. Semantic memory content in permastore: fifty years of memory for Spanish learned in
school. Journal of Experimental Psychology. General. 1984; 113(1): 1-29.
13.Squire L. On the course of forgetting in very long-term memory. Journal of Experimental Psychology.
Learning, Memory and Cognition. 1989; 15(2): 241-245.
9
CH APT E R 2
Naturalistic Decision Making

Authors: Clare Desmond, MD; Josh Kornegay, MD; Jillian Mongelluzzo, MD 
Editor: " Michael Gottlieb, MD 
A CASE
Annie was a third-year Emergency Medicine resident on her trauma rotation. A gang-
related shooting and three new traumas were about to arrive, and Annie was preparing
herself for the incoming patients. While she had assisted with trauma procedures and
practiced leading trauma resuscitations in the simulation lab, this was going to be her
first time leading a trauma resuscitation in real life.
When the patients arrived, the paramedics quickly gave a story of how one had a gunshot
wound to the chest, another had a gunshot wound to the abdomen, and a third received
one to the leg. The patient with the wound to the chest was hypoxic and in respiratory
distress. The abdominal wound patient was complaining of pain and his blood pressure
was low, and drifting lower. The leg wound was complaining of pain only.
Annie pondered the situation. It was up to her and her team must figure out how to best
approach these patients! How would she triage these new patients?
• Based upon the theory of Naturalistic Decision Making, how is this different
than if Annie were asked to evaluate and prioritize the patients in a practice
examination?
10
OVERVIEW | NATURALISTIC DECISION MAKING
Naturalistic decision making (NDM) was a theory developed by Gary Klein and Judith
Orasanu that attempts to provide a framework for how people make decisions in the
cognitively complex, real world environment.1 A central goal of NDM is to identify the
cues that experts utilize for making complex decisions.2
MAIN ORIGINATORS
Gary Klein & Judith Orasanu
• Klein G, Associates K, Ara D. Libro Naturalistic Decision Making. Hum Factors.
2008;50(3):456-460.
• Klein, G. A., Orasanu, J., Calderwood, R., & Zsambok, C. E. (Eds.). Decision making in
action: Models and methods. Norwood, NJ: Ablex Publishing Corporation, 1993.
• Lipshitz R, Klein G, Orasanu J, Salas E. Taking stock of naturalistic decision making. J
Behav Decis Mak. 2001;14(5):331-352.
• Reflections on applications of naturalistic decision making
• Klein G. Journal of Occupational and Organizational Psychology, June 2015;88(2):
382-386.
BACKGROUND
Kenneth Hammond - Cognitive Continuum Theory

• Hammond KR, Hamm RM, Grassia J, Pearson T. Direct comparison of the efficacy of
intuitive and analytical cognition in expert judgment. IEEE Trans Syst Man Cybern.
1987;SMC-17(5):753-770.
Jens Rasmussen - Cognitive Control

• Rasmussen J. The role of hierarchical knowledge representation in decision making and
system management. IEEE Trans Syst Man Cybern. 1985;SMC-15(2):234-243.
11
Prior to the development of the NDM theory, most decision-making research was
performed in a research lab setting. However, Klein and colleagues realized that
the artificial setting of the lab may not accurately represent how people make de-
cisions in their everyday lives.
In the research lab, people would typically look at all of the options and give
each of them equal weight. By observing experts in practice, however, Klein’s
group discovered that people approached decisions differently and did not com-
pare all options in an equal and systematic approach as had been seen in the re-
search lab.3 Initial NDM researchers focused on field research of individuals who
make decisions in high stakes settings. In 1989, the first NDM conference was
held and the foundation of NDM was set.4 NDM researchers discovered that peo-
ple frequently made decisions based on pattern recognition from previous experi-
ences (i.e. tacit knowledge). Prior experiences help people categorize the current
situation and choose a response based upon the category most consistent with
the current situation. However, this may not necessarily be the best response
when compared with a systematic review and analysis of all possible responses.3
One of the most popular models associated with NDM is the recognition-primed
decision model. This model explains why people can make good decisions based
on pattern recognition without comparing all the options. Initially, a person
would pattern match a situation based upon prior experiences. This is followed
by a more analytical evaluation of the response, wherein the person mentally
simulates the scenario and response. Based upon the simulation, the person will
either adapt the response to the current situation or find a new response to fit the
current situation.3
Another theory that shares similarities with NDM is the less-is-more theory pro-
posed by Goldstein and Gigerenzer.5 This theory suggests that the correct answer
can often be derived more accurately with less information. While this may ini-
tially seem counter-intuitive, the theory relies upon using only specific targeted
heuristics (e.g. recognition). As more information is added, more cues are utilized
to determine the response. However, summing the multiple cues may be less ac-
curate than relying upon the initial cue, since not all cues are equally accurate.
12
Given the number of high-pressure, high-stakes decisions made in medicine,

NDM has been increasingly studied in this field.6,7 This theory is of particular im-
portance for emergency medicine or other acute care physicians who must fre-
quently make quick and efficient decisions while simultaneously identifying the
critical “no-miss” diagnoses (low frequency, high risk diagnoses). A recent quali-
tative study using head-mounted video gear by emergency physicians found that
a physician’s differential diagnosis was primarily created before or within the
first 5 minutes of an encounter with a patient, which is consistent with the natu-
ralistic decision making theory.8 This may also be seen when emergency provid-
ers must rapidly evaluate and triage severity of injuries when selecting the order
of transport during mass casualties.
Macrocognition is a comprehensive framework that evaluates several compo-

nents of cognitive phenomena occurring in the natural environment, including
NDM, sense making, planning, adaptation, problem detection, and
coordination.3,9 This theory suggests that experts will use multiple environmental
and experiential cues to help identify the “big picture”.9 In the emergency depart-
ment, this would be represented by the more senior emergency physician identi-
fying and rapidly narrowing the differential diagnosis, while the more novice
trainee might struggle with determining the diagnosis. In high-volume or high-
acuity scenarios, previous mental rehearsal may be valuable for helping clini-
cians make sense of complex environments, as has been seen in previous studies
of critical care medicine.10
In fields combining high-stakes scenarios with short clinical decision-making

time, such as during a surgery or in the emergency department, NDM will be util-
ized to make rapid and timely decisions based upon prior knowledge. These deci-
sions may be facilitated by encouraging learners to mentally rehearse particu-
larly challenging cases, as well as supplementing the experiences with practice in
13
a simulation environment. When facing these challenges during high-stress test-
ing scenarios, the learner can be better prepared by practicing questions in a simi-
lar environment to the real test scenario. Perhaps the most significant value is in
helping learners to identify why some of their decisions may differ from experts.
The additional expertise of more senior clinicians will lead to more rapid and ac-
curate decisions in line with the NDM model.
Research on NDM is often criticized regarding its validity and methods. Bias is
often introduced since the process of decision making is frequently studied using
statements and reviewed thoughts from decision makers. Therefore, while there
is extensive qualitative data, it is challenging to have quantitative data to support
NDM. Additionally, this often contrasts the approach from Kahneman and col-
leagues, which theorizes that many decisions that involve intuition (i.e. System 1
or “fast” thinking) are not as accurate as when analytical (i.e. slow thinking) is
utilized.2 Therefore, it is important to note that during more complex or nuanced
cases, experts often forcibly slow down and think systematically, therefore avoid-
ing NDM, and devote more cognitive efforts on the task at hand.

Annie used her previous experience to quickly triage and categorize these patients. The
numerous shifts where her attending had emphasized various triage skills with multiple
14
scenarios had primed her to think through and react to this critical situation. She asked
the trauma team to evaluate the patient with abdominal pain for possible operative man-
agement, while she and the emergency team evaluated the chest wound patient, which re-
quired intubation and a tube thoracostomy. Since she knew that the leg wound was less
serious, Annie quickly wrote pain control orders for this patient before returning her fo-
cus to the more critical patients.
Annie reflected after this episode about the importance of experience, whether gained in a
real-life or simulated environment. She realized now why it was so important for her to
participate in practice oral examinations and trauma simulations about similar cases. She
reflected upon how grateful she was for the for the high-volume exposure she experienced
as a junior resident, but now this case had also fully affirmed the need to think through
and mentally rehearse similar situations prior to an actual occurrence. As she sent the
last of the three patients off to the operating room, she considered how she might utilize
this experience to benefit others during her upcoming teaching sessions.
REFERENCES
15
1. Klein G. Naturalistic Decision Making. Human Factors 2008;50(3):456-460. 

This article provides a history of the evolution of NDM. It describes the origin of NMD,
growing out of observations that decision makers frequently relied upon prior experiences
more than analytic systems when making complex decisions. The authors then discuss the
concept of the Recognition-Primed Decision Model, to illustrate the tenets of NDM. The
author also compares this with the System 1 and System 2 model of decision making.
Finally, the author discusses applications of NDM in a variety of fields, including
medicine and the military, while providing a nice flowsheet to simplify the model.
2. Lipshitz R, Klein G, Orasanu J, Salas E. Focus Article: Taking Stock of

Naturalistic Decision Making. Journal of Behavioral Decision Making
2001;14:331-352. 
This article is an extensive overview article on the history of NDM, summarizing the
research that has been performed since its emergence in the late 1980s. The authors
describe how the theory has changed in definition over time and how various models have
contributed to the overall theory. In addition to the history behind the model, the article
outlines the essential characteristics and contributions including; recognition-primed
decisions, coping with uncertainty, team decision making, decision errors, and
methodology. This article also does a good job at illustrating some of the limitations of this
decision making theory along with a stepwise approach to overcoming some of these
obstacles.
3. Kahneman D, Klein G. Conditions for Intuitive Expertise: A Failure to

Disagree. American Psychologist 2009;64(6):515-526. 
The article provides a summary of NDM in the context of the heuristics and bias theories.
This article summarizes the similarities and differences between two of the major theories
of expert decision making. Written by two of the leading authors in each field, this
provides background on each of the theories and valuable insights into both theories and
their relationship to each other.
16
1. Lipshitz R, Klein G, Orasanu J, Salas E. Taking stock of naturalistic decision making. J Behav Decis
Mak. 2001;14(5):331-352.
2. Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol.

2009;64(6):515-526.
3. Klein G, Associates K, Ara D. Libro Naturalistic Decision Making. Hum Factors. 2008;50(3):456-460.
4. Mann L. (1993) In: Decision making in action: Models and Methods. Klein GA, Orasanu J, Calder-
wood R, Zsambok CE (eds). Norwood, NJ: Ablex.
5. Brighton H, Gigerenzer G. Homo Heuristicus: Less-is-More Effects in Adaptive Cognition. Malays J

Med Sci. 2012 Oct;19(4):6-16.
6. Falzer PR. Cognitive schema and naturalistic decision making in evidence-based practices. J Biomed
Inform. 2004;37(2):86-98.
7. Cristancho SM, Vanstone M, Lingard L, Lebel ME, Ott M. When surgeons face intraoperative chal-
lenges: A naturalistic model of surgical decision making. Am J Surg. 2013;205(2):156-162.
8. Pelaccia T, Tardif J, Triby E, et al. How and when do expert emergency physicians generate and evalu-
ate diagnostic hypotheses? A qualitative study using head-mounted video cued-recall interviews.
Ann Emerg Med. 2014;64(6):575-585.
9. Schubert CC, Denmark TK, Crandall B, Grome A, Pappas J. Characterizing novice-expert differences
in macrocognition: An exploratory study of cognitive work in the emergency department. Ann Emerg
Med. 2013;61(1):96-109.
10.Fackler JC, Watts C, Grome A, Miller T, Crandall B, Pronovost P. Critical care physician cognitive task
analysis: an exploratory study. Crit Care. 2009;13(2):R33.
11.Patel VL, Kaufman DR, Arocha, JF. Emerging paradigms of cognition in medical

decision-making. Journal of Biomedical Informatics. 2002; 35(1): 52-75.
12.Hammond KR, Hamm RM, Grassia J, Pearson T. Direct comparison of the efficacy of intuitive and
analytical cognition in expert judgment. IEEE Trans Syst Man Cybern. 1987;SMC-17(5):753-770.
13.Rasmussen J. The role of hierarchical knowledge representation in decision making and system man-
agement. IEEE Trans Syst Man Cybern. 1985;SMC-15(2):234-243.
CH APT E R 3
Communities of Practice
Authors:!Andrew King, MD; Michael Abraham, MD, MS; Kevin Scott, MD 
Editor: " Teresa Chan, MD, MHPE 
A CASE
Steve, who recently completed his emergency medicine residency and medical education
fellowship, had just joined a new institution as a heavily recruited junior faculty member.
He was successful as a resident and a fellow with several scholarly projects and both
regional and national lectures. Steve was ambitious and hoped to translate his success to
his new institution with the goal of ultimately becoming a member of the residency
program leadership.
He quickly assimilated himself into the many available resident and medical student
education opportunities. Learners frequently lauded Steve for both his willingness and
his ability to teach. For his efforts, Steve was awarded the departmental Teacher of the
Year award based upon his excellent evaluations.
Despite his “overnight” success, Steve was not satisfied. His accolades were coming
mainly from the people he was teaching, and he wondered why the senior educators and
departmental leaders had not recognize his achievements? He was still working a full
clinical load and had not yet received the departmental support for his educational
endeavors and scholarly activity that he was promised. He finally arranged a meeting
with the department chair asking about the status of the departmental support he was
promised; however, the chair claimed that he did not recall this agreement and that
departmental support is dependent upon scholarly activity. Steve proclaimed that
scholarship is extremely difficult while working a full clinical and teaching load. He also
18
explained that he was honored to have received Teacher of the Year and has a successful
past track record. The chair congratulated him, yet remained steadfast that departmental
support is commensurate with scholarly output.
Steve was very discouraged by his discussion with his chairperson; however, he accepted
the feedback as motivation to improve. How was he going to successfully complete
scholarly projects while working a full clinical load? Steve’s answer to the preceding
question was to enlist the help of a mentor. He had lost touch with faculty from his
residency and fellowship since joining his new institution, so he began reaching out to
seek a mentor within his current department. He targeted senior education faculty who
have had successful careers with medical education scholarship. Emails were sent and
meetings were held, but Steve never received the mentorship he was promised. Potential
mentors often told him that they were too busy to mentor such a young faculty member.
Senior faculty also told him they didn’t have advice because they received departmental
support throughout their career.
Once again dejected over a broken promise and lack of mentorship, Steve reached out to
residents and medical students interested in assisting with scholarship. The opportunity
to mentor residents and medical students reinvigorated Steve; however, they were only
interested in performing case reports. Steve successfully mentored residents and
published several case reports, but this was not the scholarly productivity that interested
Steve. He felt alone within the department, lacking support and mentorship. He could
feel his ambition declining and his career trajectory was blurring. Steve recognized that
he needed a break and time to reflect, so he decided to attend a national emergency
medicine education meeting in hopes of reinvigorating his career passion or identifying
an alternative career path.
Questions for the Reader
• How should Steve approach this dilemma?
• Are there resources or programs available to assist Steve?
19
OVERVIEW | COMMUNITIES OF PRACTICE
Communities of practice (CoPs) are part of the family of social learning theories. CoP
are neither legislated nor formally mandated; they simply develop in response to a
specific need. The underlying principle is that learning occurs through social
engagement in authentic contexts.1
Specifically, CoPs are comprised of individuals that share a particular interest and
interact together based on this domain. The foundation of the community is built
upon the interactions of the members with each other and their shared experiences of
personal engagement within the context of a shared practice.
Through these interactions, resources are created that are valued by the community.
The most general role of a CoP is the advancement of expertise within the shared
context. Specific outcomes of interactions and collaboration may include learning,
innovation, and the spreading of knowledge regarding the particular domain of the
CoP; recognizing that particular outcomes may not have been the initial intention of
the community.2
MAIN ORIGINATORS
Jean Lave & Etienne Wenger
• Lave J, Wenger E. Situated learning: Legitimate peripheral participation. Cambridge
university press; 1991 Sep 27.
• Wenger E. Communities of practice: Learning, meaning, and identity. Cambridge
university press; 1998.

Virtual Communities of Practice (vCoP) were later introduced as an adjunctive concept by 
L. Dubé and A. Bourhis:

• Dubé L, Bourhis A, Jacob R. The impact of structuring characteristics on the launching
of virtual communities of practice. Journal of Organizational Change Management.
2005 Apr 1;18(2):145-66.
• Dubé L, Bourhis A, Jacob R. Towards a typology of virtual communities of practice.
Interdisciplinary Journal of Information, knowledge, and management. 2006 Jan 1;1(1):
69-93.
20
BACKGROUND
The term Community of Practice (CoP) was first coined in 1991 by Jean Lave and
Etienne Wenger.1 They suggest that the concept of communities of practice has
been present though the entirety of humankind, and that the groups may evolve
spontaneously as a result of the need to solve a unique problem or accomplish a
particular task, although the most productive are likely cultivated.2 Lave and
Wenger described a CoP while studying apprenticeship. They identified that
rather than apprenticeship being an isolated learning process between student
and master, there were complex social interactions, resulting in many learners
and different levels of apprentices within a domain. The impact of social relation-
ships on social learning underpins the idea of a community of practice.3
CoPs are comprised of the three following foundational elements:
1. A domain
2. A community
3. A practice.
The domain refers to the shared interest of the group. A community develops as
a result of interactions and collaboration surrounding the domain. Through
these interactions, the community forms a practice that leads to the compilation
and development of resources that serve the group.3,4 Over the existence of the
CoP, continued growth and transformation of the community occurs through the
continued development of these three elements.2
CoP are found in many different fields, with the purpose often being to improve
in some aspect of understanding, performance, or knowledge. The knowledge
base of the community is expected to be greater than that of an individual. As
the community’s knowledge expands, whether that is through increased partici-
pation or acquisition of knowledge, so does that of the individual participants’
within said community.
The basis of knowledge expansion is through discussion and collaboration of

members, which is similar by other social learning and constructivist approaches
to education. Although knowledge is one potential outcome of a community of
21
practice, a significant achievement is more likely in innovation within the particu-
lar field of interest. Building of knowledge and innovation results in the contin-
ued evolution of the group and its members. CoPs often exist over extended peri-
ods of time and experience variability of participation. In addition to the collabo-
rative basis of growth, the dynamic nature of the community results in continued
introduction of new experiences, ideas, and innovations that serve as the basis
for continued advancement of the community and its individuals.5
When a new member enters into a new CoP, their participation is often described
by Lave & Wenger as “legitimate peripheral participation” (LPP).1 New members
are often welcomed into a CoP by participating in low-stakes, simpler tasks that
still hold value to the community.1 The idea is that via these introductory tasks
new members learn and grow thereby acquiring skills, knowledge, language,
and a sense of the implicit culture of the CoP.1 LPP opportunities where the new
members can actually observe or collaborate with more experienced members
can expedite the growth of the more inexperienced members.1
In many ways, Steve’s participation within his local group can be seen as a form
of LPP, since he is participating in low-stakes projects with the residents and
medical students, learning the craft of supervising and mentoring others. The
problem in his situation is that within his locale he seems to lack the mentors that
can help him to grow (either by explicit apprenticeship or by passively observing
their actions within the CoP).
Communities of practice can exist in many different forms and typically have a
degree of informality and frequent connectivity among community members.
With the continuous advancement of technology, members of communities of
practice have benefited in several ways.
A community of practice can certainly occur within a local work environment or

educational setting; however, technological advances, the explosion of social me-
dia, and the development of virtual or online communities have resulted in new
innovations and opportunities for improving the functionality and accessibility
22
of a community or practice. The initial community of practice theory developed
by Lave and Wenger focused on the linking of people with similar interests and
practices within a local or restricted area.1
Dubé & Bourhis have written extensively about the emergence of the virtual
Community of Practice (vCoP),7,8 which is a more digitally-oriented extension of
the conceptual framework first described by Lave & Wenger.1 With the develop-
ment and increased utilization of online communities like Google Hangouts/
Groups, Slack, and Vsee, members of a vCOP can be in different locations
throughout the country or even the world and remain active participants in com-
munity discussions, activities, and output. Members with diverse backgrounds,
different professional training, and regional practices result in communities with
numerous ideas and unique output given the various points of view.
The work by Bourhis & Dubé9 have suggested that success of a vCoP may hinge
on a number of structuring characteristics such as:
• The amount of time the leader can devote to the community

• The leader’s selection based on his/her personality, enthusiasm, and skills
• The presence and selection of a coach.
Having a dedicated, full-time leader has been shown in this previous work to be
of great benefit.10 When launching a new vCoP it is also important to consider
the environment in which the vCoP is launched.10 Groups that have a surround-
ing “obstructive environment” are likely doomed to fail.10 Having support from
established organizations/institutions was also found to be helpful for nascent
vCoP.10
The advent of online or virtual CoP has resulted in some very successful groups
measured by participation and output. Within emergency medicine education,
Academic Life in Emergency Medicine (ALiEM), created by Michelle Lin, has cre-
ated multiple successful communities of practice for physicians at differing
stages of their career. These communities of practice, referred to as “Incubators,”
include cultivated networks for chief residents (Chief Resident Incubator), fel-
lows (Fellowship Incubator), and more recently, junior faculty members (Faculty
Incubator). Members of these online communities of practice have the opportu-
23
nity to collaborate, learn from one another, and produce tangible scholarship
products aimed at advancing emergency medicine education. Members of these
emergency medicine virtual communities of practice collaborate with other mem-
bers and mentors with unique interests, different backgrounds, and perhaps re-
gional variation in clinical and educational practice given the widespread reach
of these virtual communities. Members exist throughout the United States, Can-
ada, and even South America!
An interesting aspect of CoPs is that they can be either cultivated or occur sponta-
neously. Examples of cultivated CoPs can be found in various realms of under-
graduate medical education. Practically, the central concept of these CoPs is that
participants are of varying levels of expertise and participate in domain specific
activities that promote both content and tacit knowledge, and potentially innova-
tion.
One example from the Perelman School of Medicine at the University of Pennsyl-
vania is the “Doctoring Course” where MS1 and MS4 students, along with a few
faculty, are divided into large groups and spend several semesters exploring the
complex psychosocial aspects of the doctor-patient relationship. The groups
meet weekly to share personal experiences and thoughts surrounding topics such
as communication, culture, spirituality, religion, race, social disparities, profes-
sionalism, and ethics in order to develop a better understanding of relationships
and a framework for guiding interaction. Although there is a guide for topics to
be discussed, the group and individual members determine what knowledge and
skill set they take away from the group discussions.
Another example was raised by one of our open peer reviewers (Dr. Rowan
Duys, @HealThink), who noted that trainees seemingly gravitate towards vCoP
in his locale, even though they have little access to the internet via computers.
Mostly, he has noted, that the learners in the lower-resourced setting of his coun-
try in South Africa access virtual groups via mobile devices, using Facebook or
WhatsApp to connect. If these groups have layered expertise (i.e. both appren-
24
tices and experts), and if they connect people within a community of a shared
trade or “practice”, then these truly are emergent vCoP. As Dr. Michelle Lin
(@M_Lin) pointed out during our open peer review, “transitioning CoP’s from
in-person to online in the health professions arena, however, has its advantages
and disadvantages. While convenient, virtual communities are challenged by is-
sues of accountability, communication (e.g. the tone of emails and text messages
can be misconstrued, leading to mistrust), community cohesiveness without the
watercooler effect, and psychological safety.”11 These are all practical considera-
tions when one is seeking to establish a new vCoP.
During our online peer review process, Dr. Damian Roland (@Damian_Roland)
wished for us to more fully explore more of the mechanics of setting up or creat-
ing a community of practice.12 As such, we will point out that the core elements
(The Domain, The Community, The Practice) may not be sufficient to create a
community. Stakeholders with a vested interested in connecting people within
the community, with passion and time, can be very key. There is a predominant
myth that CoP are spontaneously organized by individuals. While the origin of
CoP may be more or less spontaneous, they require active participation of all
members of different levels (from the apprentice to the master) to ensure high re-
turn of time investment. Having champions (e.g. leaders) may be useful in culti-
vating this sentiment. But facilitation is by no means sufficient; the domain must
also be relevant or else the members will not see the point in connecting.2 Moreo-
ver, members’ participation should result in a tangible benefit - which is why hav-
ing a shared practice as manifest by activities may be key.2
Finally, CoP needn’t be only informal. As Lave & Wenger point out, it should be
noted that within organizations, CoP are often labeled under different names
(e.g. networks, thematic groups, clubs, societies, working groups).2 For instance,
some medical schools have fostered the concept of CoPs with ‘Academic Socie-
ties’ or ‘Houses of Learning’ that help establish and allow for mentorship and
education surrounding the societal aspects of medical education. National socie-
ties may have ‘Working Groups’ or ‘Sections’. These CoPs establish the founda-
tion for societal learning, where everyone has a vested interest and is an active
participant to promote their individual educational requirements.
25
The interpretation of Community of Practice is in a constant state of evolution.

As a result, the best role for implementing this type of learning community re-
mains unclear. Furthermore, due to varying motivations for the development of
CoPs, there remains difficulty in identifying and measuring outcomes, leaving a
lack of evidence for their impact on individual and group learning. Additional
limitations include balancing the growth of individuals with that of the group
and a functional dependency on member buy-in and participation, which is reli-
ant on a high level of trust amongst the community. Furthermore, as with other
constructivist and situated learning frameworks, the blurred lines between
teacher and learner, although potentially encouraging further group interaction,
may leave others reticent to joining in.6 Overall, as we continue to see the devel-
opment of CoPs in the healthcare setting, our understanding and the effective im-
plementation of these learning groups will be reliant on the continued elucida-
tion of others’ experiences…perhaps a CoP on CoPs.

While attending the national emergency medicine education conference, Steve registered
for a few sessions specifically dedicated to medical education and junior faculty develop-
ment. These sessions allowed him to meet other junior faculty members from across the
country who reassured him that they were experiencing similar struggles. He was also ex-
posed to several mentors and educators within emergency medicine education who intro-
duced him to the power of an online community of practice. He remembered learning
about the Lave & Wenger theory as a Medical Education fellow, but never considered him-
self a member within that community of practice.
Mentors and attendees encouraged him to join an established virtual community of prac-
tice consisting of junior faculty participants and mentors from across the country. He
was able to remain an active participant in this program while working a full clinical load
because he was able to check the online forum and participate when he had time. This pro-
gram allowed him to collaborate with other junior faculty members while receiving peer
peer coaching and professional growth within a group. Because of this collaboration and
26
mentorship, Steve’s scholarly output exploded with peer-reviewed publications, national
lectures, and invited lectures. He became reinvigorated, and his passion for his career re-
turned.
Because of his exuberant success, the unthinkable happened: Steve’s accomplishments

were eventually recognized by his department chair and he received departmental support
by being named a core faculty member and assistant residency program director.
Unfortunately, Steve’s problem remains common in academic emergency medi-

cine. Communities of practice, specifically virtual communities of practice, can
provide the mentorship and collaboration that many junior faculty members lack
within their own institutions.
27
1. Communities of practice: A brief introduction. http://wenger-trayner.com/

introduction-to-communities-of-practice/ Published April 15, 2015. Accessed
June 6, 2016 
This website is a great overview of the beginnings and development of the concept of
communities of practice. In addition, the authors discuss the variety of organizations and
setting where one can find CoPs, while also addressing many misconceptions.
2. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC, Graham ID. Evolution of
Wenger’s concept of community of practice. Implement Sci. 2009; 4(11):1-8. 
This paper is a useful tool for better understanding the limitations of communities of
practice with regards to their role in health professions education. This paper sheds light
on the varying interpretations of CoPs and the lack research into their effectiveness.
3. Polin LG. Graduate Professional Education from a Community of Practice

Perspective: The Role of Social and Technical Networking. In: Blackmore C, ed.
Social Learning Systems and Communities of Practice. 1st ed. London, UK:
Springer; 2010:163-178. 
This book chapter examines more closely the social aspects that underlie the concept of
communities of practice. Additionally, it discusses the role of CoPs in graduate
professional education and the role of technology in cultivating these learning
communities.
4. Lin M, Sherbino J. Creating a virtual journal club: a community of practice

using multiple social media strategies. Journal of graduate medical education.
2015 Sep;7(3):481-2. 
This paper discusses how a virtual journal club using various social media platforms can
form communities of practice that involves groups of people who share a passion for
something they do and learn how to improve based on frequent interactions.
5. Sherbino J, Snell L, Dath D, Dojeiji S, Abbott C, Frank JR. A National Clinican

Educator Program: A Model of an Effective Community of Practice. Med Educ
Online. 2010 Dec 6; 15.  
This paper introduces another example of a successful community of practice. A national
clinician educator program was developed using the community of practice model. Several
benefits were identified including: improved problem solving, recognition of educational
needs, development of new projects, and improved professional satisfaction. 
28
REFERENCES
1. Lave J, Wenger E. Situated Learning. Legitimate peripheral participation. Cambridge: University of
Cambridge Press. 1991.
2. Communities of practice: A brief introduction. Published April 15, 2015. Accessed June 6, 2016. Avail-
able at: http://wenger-trayner.com/introduction-to-communities-of-practice/
3. Wenger E. Communities of practice: learning as a social system. The Systems Thinker. 1998; 9(5):1-11.
4. Smith, MK. Jean Lave, Etienne Wenger and communities of practice. The Encyclopedia of Informal
Education. www.infed.org/biblio/communities_of_practice.htm. Published 2003. Updated 2009. Ac-
cessed June 6, 2016.
5. Polin LG. Graduate Professional Education from a Community of Practice Perspective: The Role of
Social and Technical Networking. In: Blackmore C, ed. Social Learning Systems and Communities of
Practice. 1st ed. London, UK: Springer; 2010:163-178.
6. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC, Graham ID. Evolution of Wenger’s concept of
community of practice. Implement Sci. 2009; 4(11):1-8.
7. Dubé L, Bourhis A, Jacob R. The impact of structuring characteristics on the launching of virtual com-
munities of practice. Journal of Organizational Change Management. 2005 Apr 1;18(2):145-66.
8. Dubé L, Bourhis A, Jacob R. Towards a typology of virtual communities of practice. Interdisciplinary

Journal of Information, knowledge, and management. 2006 Jan 1;1(1):69-93.
9. Bourhis A, Dubé L, Jacob R. The success of virtual communities of practice: The leadership factor. The
Electronic Journal of Knowledge Management. 2005 Jul;3(1):23-34.
10.Dubé L, Bourhis A, Jacob R. The impact of structuring characteristics on the launching of virtual com-
munities of practice. Journal of Organizational Change Management. 2005 Apr 1;18(2):145-66.
11.Lin M. Comment on Education Theory Made Practical: Communities of Practice. Available at:
https://icenetblog.royalcollege.ca/2017/02/10/community-of-practice/ Accessed June 12, 2017.
12.Roland D. Comment on Education Theory Made Practical: Communities of Practice. Available at:
https://icenetblog.royalcollege.ca/2017/02/10/community-of-practice/ Accessed June 12, 2017.
29
CH APT E R 4
Emotional Intelligence
Authors:!Lauren Conlon, MD; Kory London, MD; Michael Pasirstein, MD, MPH. 
Editor: " Teresa Chan, MD, MHPE 
A CASE
Omar, a second year emergency medicine resident, had recently finished a six-week long
stretch of shifts in the emergency department and had moved onto an administrative
rotation when he was called into the program director’s office. The program director was
notified by clinical leadership in the department that there had been a number of recent
complaints received from patients and nurses over the past few weeks regarding his
performance. Omar had always scored at the top of his class with marks above the 95th
percentile for the in-service exam and he had performed well clinically during his intern
year.
He was one of the quieter residents and typically flies below the radar on shifts. He was
not overly emotional and is one of the more soft-spoken residents. When he met with the
program director, Lara, he is unaware of the reason.
“Thank you for meeting with me Omar. We need to review your performance over the
past few weeks in the emergency department as there were some comments made by
patients and nurses about your interactions with them. Were you aware of any difficult
situations over the past few weeks when you were working in the department?” asked
Lara, the program director.
30
Omar is not sure how to respond. “Not really, what kind of comments?”
Lara hands him a piece of paper with the following comments:
Patient Complaint 1: “The resident didn’t listen to me”
Patient Complaint 2: “He didn’t seem very happy to be there and was rude”
Nursing Complaint: “Omar is consistently dismissive of suggestions made by nursing

staff and does not communicate his plans effectively.”
• How can the theories of Emotional Intelligence help us to understand the

current situation?
31
OVERVIEW | EMOTIONAL INTELLIGENCE
Emotional intelligence is an umbrella term describing the processes of

cognitive awareness and flexibility in human interaction.
At its peak, it refers to a high level of emotional discrimination and the

synergistic ability to use that information to respond in an empathic manner.
MAIN ORIGINATORS OF THE THEORY
There are numerous key thought leaders within this area:

• Hanscarl Leuner - Emotional intelligence and emancipation (1966)
• Daniel Goleman – Emotional intelligence (1995)
• Peter Salovey and John Mayer – Emotional intelligence (1990)
Harold Gardner
• Frames of Mind: The Theory of Multiple Intelligences (1983)
Wayne Payne
• Study of Emotion: Developing Emotional Intelligence; Self- Integration;
Relating To Fear, Pain And Desire (1985).
32
BACKGROUND
Emotional Intelligence (EI) was first described in child psychology literature in

19661 and later popularized in the 1980s when EI or ‘EQ’ (Emotional Quotient)
was introduced as a way to explain cognitive ability in contrast to the traditional
Intelligence Quotient or “IQ”.2,3 While viewed with skepticism by academic psy-
chologists initially, the framework took hold in popular culture. Now used by
large businesses and leaders to improve the processes and function of their work-
ers, the framework continues to be refined through various models.
Three of those models of emotional intelligence exist:
• the ability model

• the mixed model
• trait model.4-6
1. The Ability Model
The ability model7,8, described by Peter Salovey and John Mayer in the late 1980s,
addresses four levels of emotional intelligence:
1. Perception and expression of emotions accurately

2. Utilization of emotions to facilitate thinking
3. Understanding and analyzing emotions
4. Regulating and managing emotions appropriately in yourself and others
 
Subject to the largest number of research studies, it has been criticized for poor
practical outcomes and correlation with other measures.9 Other models have sub-
sequently shown better predictive value.10
2. The Mixed Model
The mixed model, described by Daniel Goleman in the 1990s,11 identifies charac-
teristics of emotional intelligence that drive leadership performance, namely:
33
1. Self-awareness
2. Self-regulation
3. Social skill
4. Empathy
5. Motivation. 
The characteristics are interconnected. For example, as one becomes more self
aware, they are better able to regulate their emotions and social skills. The subject
is better able to manage stressful situations and interpersonal conflicts, and the
subsequent success is self-propagating. This model and its author is the basis of
the popularity of the EI framework, through his book ‘Emotional Intelligence’
(1995). This model, and Goleman’s approach in general, has also received a large
amount of criticism due to the the lack of a consistent relationship between his
pillars of EI and participant performance. When EI has been studied with gen-
eral intelligence and personality controlled, its effect has been muted.12,13
 
3. The Trait Model
The trait model, described by Petrides in the 2000s, describes EI as a personality

framework and refers to an individual’s perception of their own emotional
abilities.14,15 Developed more recently, the trait model elucidates central parts of
the mixed model while rejecting the ability model’s behavioral focus. By focus-
ing on personality traits, the model requires self-assessment and is highly reliant
on the self-awareness of individuals to effectively judge a subject’s personality. In
medical students, it has been shown to be more effective as a measure of personal-
ity than the ability model.
The work studying EI in the era of virtual interaction is an embryonic science. As

distance education becomes increasingly prevalent, understanding how EI might
manifest in virtual or online communities will be of great importance. While not
directly studied in medicine, multiple studies18,19 have shown that EI is relevant
to effective leadership in the virtual world. Strong communication skills where
34
visual cues may not be apparent are more vital to the success of groups. Work on
a new framework for virtual EI is ongoing.
More eye contact leads to more effective communication and perception of emo-
tion. Physicians who looked more frequently at patients were more successful in
recognizing psychological distress.20
The primary way we read emotions is non-verbal: <10% is spoken word, ~40%
verbal tone, ~50% facial expression.21 Similarly, patient satisfaction was most
strongly correlated to emotional expressive nonverbal behavior on the part of the
clinician.22 Physicians who were better at expressing their emotions had patients
who rated them as listening more and being more caring and sensitive than those
doctors who were less adept at this.23
Labeling patient’s emotions can help with empathy.24 Starting an interview with
a patient who is visibly upset may be best managed by labeling this emotion.
Physicians infrequently use emotional language and a conscious effort may be
necessary.25
Positive and negative emotions are contagious in the group setting, especially
when demonstrated by the leader of a group.26 This can be particularly impor-
tant in the clinical setting when working in teams; specifically in a resuscitation
or crisis event.
35
Lara asked Omar about his thoughts on the feedback he just received, as Omar appeared
visibly upset. To her surprise, though he very casually replied that he was fine. Omar was
looking away and his arms are crossed. At that moment, it became clear to Lara that the
problem is...
Lara asked Omar if he recognized what his current body language was indicating to her.
He sheepishly replied, “No, not really.”
Although Omar was embarrassed, he quickly admitted to Lara that he had struggled with
social interaction all his life, as that it does not come naturally to him. Omar admitted to
her that he wanted to improve, and continued to add that he would not be interested in
seeking a therapist. However. Omar stated that his adviser in medical school attempted
multiple times for him to seek mental health treatment, but Omar did not want any asso-
ciated stigma.
Surprised that mental health was the only prior suggestion offered, Lara asked Omar if he
had ever encountered a concept called ‘emotional intelligence’. When he indicated that he
was not, she offered some some observations and the contact information for a local coun-
sellor specializing in the area.
At the conclusion of their discussion, Omar and Lana were able to agree on a plan. Omar
suggested that he lead a 30-minute talk on emotional intelligence during the residency’s
weekly conference, to make more residents aware of the concept. He and Lana both noted
that many others could also benefit from this new knowledge. In preparation, Omar set
forth to review current literature and provide a succinct workshop on methods that physi-
cians at all levels can implement.They also agreed to set up weekly check-ins to discuss
his interactions. His first goal was to maintain eye contact, for at least a short period of
time, with every patient encounter.
A week later, Omar was inspired by his readings and suggested that his next goal be to ex-
plore how physical presence can affect his patient interactions - he had set forth to add a
firm handshake upon introducing himself, but also had begun sitting down next to his pa-
tients, and being cognizant to avoid crossing his arms.
36
1. Mayer JD, Salovey P, Caruso DL, Sitarenios G. Emotional intelligence as a standard
intelligence, 2001. 
This paper lays forth the opinion of that the ability model of EI has validity as a form of
intelligence. They review the key tenets of intelligence, frameworks of abstract reasoning, as well
as emotions, complex mental responses to physical and cognitive stimuli. They discuss
criticisms of their work as well as the data and literature that support their work. In particular,
they spend time discussing how there can be objective answers to emotional questions that arise
aside from general consensus.
2. Cartwright S and Pappas C. Emotional intelligence, its measurement and
implications for the workplace. International Journal of Management Reviews
2008:10;149-171. 
This article attempts to remove the popular hype that accompanies the theory of EI and find
concrete evidence of where it works to improve workplace performance and where it doesn’t.
They begin by discussing the view of emotion in workplace functionality. It initially was
viewed negatively, as constructs that interrupt the inherently rational exercise of business.
They then review the models of EI and how they pertain to the workplace. Also, they also make
note of the common criticism that EI has become commercialized and that it is too reliant on
self-assessment, which are prone to error and intentional distortion. Regardless, the meat of the
article is a review of the literature, which reveals positive correlations between EI and workplace
performance, leadership effectiveness, openness to change and effectiveness in service
encounters. Similarly, there are also negative correlations between EI and dysfunctional
behaviors.
3. Brannick MT, Wahi MM, Arce M, Johnson HA, Nazian S, Goldin SB. Comparison of
trait and ability measures of emotional intelligence in medical students. Med Educ.
2009 Nov;43(11):1062-8. 
For those who wish to use EI in the health care educational setting, there is a limited but real
fund of literature. This particular study attempts to evaluate if either the ability or trait
measures of EI is more highly correlated to conventional personality characteristics
(neuroticism, extroversion, openness to new experiences, agreeableness and conscientiousness).
It also attempts to study if measures of trait and ability EI correlate to each other. In this study
of medical students, it was found that the trait measure of EI (in this case a test known as
WLEIS) correlates to the aforementioned personality traits better than the ability measure. The
measures of trait and ability EI do not correlate, leading to a concern that while they describe
similar phenomena, they may not actually measure the same underlying construct. Finally, the
reference list of this article is the best source of studies looking at EI in the field of medical
education that could be found.
37
REFERENCES
1. Leuner B. Emotional intelligence and emancipation. A psychodynamic study on women. Praxis der
kinderpsychologie und kinderpsychiatrie. 1966 Jan 1;15(6):196-203.
2. Payne W.L. A study of emotion: developing emotional intelligence; self integration; relating to fear,
pain and desire" Dissertation Abstracts International 47, 1985 p. 203A (University microfilms No. AAC
8605928)
3. Beasley K. The emotional quotient. Br. Mensa Mag. 1987 May:25.
4. Mayer JD, Roberts RD, Barsade SG. Human abilities: Emotional intelligence. Annu. Rev. Psychol.. 2008
Jan 10;59:507-36. doi:10.1146/annurev.psych.59.103006.093646
5. Kluemper DH. Trait emotional intelligence: The impact of core-self evaluations and social desirability.
Personality and Individual Differences. 2008 Apr 30;44(6):1402-12. doi:10.1016/j.paid.2007.12.008
6. Martins A, Ramalho N, Morin E. A comprehensive meta-analysis of the relationship between emo-

tional intelligence and health. Personality and individual differences. 2010 Oct 31;49(6):554-64.
doi:10.1016/j.paid.2010.05.029
7. Mayer JD, Salovey P, Caruso DR, Sitarenios G. Emotional intelligence as a standard intelligence. Emo-
tion 2001;1: 232–242. doi:10.1037/1528-3542.1.3.232
8. MacCann C, Joseph DL, Newman DA, Roberts RD. Emotional intelligence is a second-stratum factor
of intelligence: Evidence from hierarchical and bifactor models. Emotion. 2014 Apr;14(2):358.
9. Van Rooy DL, Viswesvaran C. Emotional intelligence: A meta-analytic investigation of predictive va-
lidity and nomological net. Journal of vocational Behavior. 2004 Aug 31;65(1):71-95.
10.Weng HC, Hung CM, Liu YT, Cheng YJ, Yen CY, Chang CC, Huang CK. Associations between emo-
tional intelligence and doctor burnout, job satisfaction and patient satisfaction. Medical education.
2011 Aug 1;45(8):835-42.
11.Goleman D. Working with emotional intelligence. New York, Bantam Books; 1998.
12.Zeidner M, Matthews G, Roberts RD. Emotional intelligence in the workplace: A critical review. Ap-
plied Psychology. 2004 Jul 1; 53 (3): 371-99.
13.Cavazotte F, Moreno V, Hickmann M. Effects of leader intelligence, personality and emotional intelli-
gence on transformational leadership and managerial performance. The Leadership Quarterly. 2012
Jun 30;23(3):443-55.
14.Petrides KV, Furnham A. Trait emotional intelligence: Psychometric investigation with reference to
established trait taxonomies. European journal of personality. 2001 Nov 1;15(6):425-48.
15.Petrides KV, Pita R, Kokkinaki F. The location of trait emotional intelligence in personality factor
space. British Journal of Psychology. 2007 May 1;98(2):273-89.
38
16.Brannick MT, Wahi MM, Arce M, Johnson HA, Nazian S, Goldin SB. Comparison of trait and ability
measures of emotional intelligence in medical students. Medical education. 2009 Nov 1;43(11):1062-8.
17.Berenson R, Boyles G, Weaver A. Emotional intelligence as a predictor of success in online learning.

The International Review of Research in Open and Distributed Learning. 2008 Jun 30;9(2).
18.Ambrose P, Chenoweth J, Mao E. Leadership in virtual teams: the case for emotional intelligence. AM-
CIS 2009 Proceedings. 2009 Jan 1:626.
19.Pitts VE, Wright NA, Harkabus LC. Communication in virtual teams: The role of emotional intelli-
gence. Journal of Organizational Psychology. 2012 Sep 1;12(3/4):21.
20.Bensing J. Doctor-patient communication and the quality of care. Social science & medicine. 1991 Jan
1;32(11):1301-10.
21.Mehrabian, Albert (1971). Silent Messages (1st ed.). Belmont, CA: Wadsworth. ISBN 0-534-00910-7
22.Griffith CH, Wilson JF, Langer S, Haist SA. House staff nonverbal communication skills and standard-
ized patient satisfaction. Journal of general internal medicine. 2003 Mar 1;18(3):170-4.
23.DiMatteo MR, Taranta A, Friedman HS, Prince LM. Predicting patient satisfaction from physicians'
nonverbal communication skills. Medical care. 1980 Apr 1:376-87.
24.Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medi-
cal interview. JAMA. 1997 Feb 26;277(8):678-82.
25.Shields, C.G., Epstein, R.M., Franks, P., Fiscella, K., Duberstein, P., McDaniel, S.H. and Meldrum, S.,
2005. Emotion language in primary care encounters: reliability and validity of an emotion word count
coding system. Patient education and counseling, 57(2), pp.232-238.
26.Barsade SG. The ripple effect: Emotional contagion and its influence on group behavior. Administra-
tive Science Quarterly. 2002 Dec;47(4):644-75.
39
CH APT E R 5
Social Constructivism
Authors: Eric Cioè Peña, MD, MPH; Abra Fant, MD, MS; Anne Messman, MD 
Editor: " Jonathan Sherbino, MD, MEd 
A CASE
Mira was an assistant program director for an urban, semi-academic residency program.
Because of her love for teaching and curriculum innovations, she was recently put in
charge of the weekly didactics that the residents attend for 5 hours per week.
When she first started her job as assistant program director, she felt that the didactics
were generally strong. The design was mediocre, but she wondered “how interesting are
core curriculum lectures, anyways?” There was a good mix of attending and resident
lectures each week. The curriculum tried to adhere to a systems-based approach, focusing
on one topic per month; although this was sometimes impossible because of scheduling
constraints. Lecture attendance was reasonable, yet only a handful of residents seemed to
engage or ask questions during the sessions.
Once assigned the task of overseeing the weekly didactics, Mira started to analyze the
lectures. When she critically observed the sessions, Mira realized that many people
seemed to be paying more attention to their phones than to the lecture. Several had
laptops opened on their desks and were clearly working on other projects. A couple of
residents were even asleep! Mira realized that perhaps these didactics weren’t as good as
she had previously thought.
40
Mira decided to intervene. She sent an anonymous survey to the residents, asking their
thoughts about the current weekly didactics, and asked for suggestions. The response of
the residents floored her! They complained about “death by powerpoint” and called the
material “extremely boring.” The residents expressed an interest in greater interactivity
during sessions. Many stated that they didn’t learn by being “lectured at.” One person
even wrote: “there are a million excellent podcasts out there, why don’t we just listen to
them for 5 hours? Why are we reinventing the wheel?”
Mira started to feel insecure about the current state of her newly assigned weekly didactic
sessions, realizing she had a much bigger job than initially anticipated. She did some
research online and learned about some innovative ideas that some residency programs
were implementing. Should the program adopt a “flipped classroom” model? That would
require a total overhaul of the curriculum, something Mira wasn’t certain she could
handle. Was it a reasonable suggestion to start listening to podcasts or watching videos
from experts during the time allotted for didactics? Such an approach might increase the
quality of the presentations, but would not address the issue of improving active learning.
Maybe the residents would get more out of didactics if they were divided by training level
and given lectures mapped to their level of training? That seemed like a good idea, but the
design would require three lecturers every hour instead of one.
Mira wondered if there was anything she could easily do to increase the quality of the
sessions without a complete overhaul of the curriculum.
• Mira is facing a very common challenge. What sort of theories might inform
the way she could improve her curriculum?
41
OVERVIEW | SOCIAL CONSTRUCTIVISM
To understand social constructivism requires understanding what constructivism
means. In terms of educational theory, constructivism perceives that “the
learning environment is one of experimentation and dialogue, where knowledge is seen
within the context of problems to be discussed and solved.”1 Put another way,
constructivism involves the interpretation and explanation of information within
the context of previous experiences and existing knowledge. Knowledge is not
transferred from teacher to learner in a passive, hierarchical manner; there is no
single, absolute interpretation of information. Rather, information is processed
through what is already personally known with new understanding (i.e.
interpretation of information) constructed in a manner unique to the individual.
Social constructivism takes the theory of constructivism a step further and states
that information is influenced by the social environment with interpretation and
construction of knowledge influenced by other learners and teachers. Social
constructivists posit that comprehension is first constructed on an inter-
psychological level (i.e. between people). Once this is accomplished
interpretations can be internalized (i.e. becomes intra-psychological).
Social constructivists argue that teachers should provide coaching, framing and
guidance, not passively convey information in a one-way direction to their
students. Students learn from performing, interacting, and experimenting with
the material, while the teacher assists in the design, facilitation, and presentation
of the curriculum. A teacher may be defined in many ways, including another
peer learner, a learning resource, a content expert, or anyone with
complementary or additional knowledge on a topic.
Social constructivists believe that traditional forms of assessment (e.g., written

tests) may not assess a learner’s deeper comprehension of the material.
Traditional tests of knowledge may only test the learner’s ability to interpret and
respond to the superficial requirements of the test. Social constructivists favor a
model where assessment is “embedded within the learning and teaching
process.”1 Assessment instruments that assess higher reasoning, such as analysis
and synthesis, are favoured.
42
• Lev Vygotsky
• Peter Berger & Thomas Luckmann

• Giambattista Vico
• Jean Piaget
• Ernst von Glasersfeld
• John Dewey
BACKGROUND
Social constructivism is categorized under constructivist theories. Constructivism

dates to Giambattista Vico, an Italian philosopher of the 1700s, who felt that “the
learner learns to construct knowledge for himself based on what he can explain.”2 Other
psychologists refined the theory of constructivism (Piaget, von Glasersfeld,
Dewey), but it was Vygotsky’s social development theory that influenced the de-
velopment of social constructivism. Vygotsky articulated that learning cannot oc-
cur passively with a teacher at the front of the classroom reciting facts and the stu-
dent passively absorbing this information. He felt that “the learner needs to under-
stand the lesson in a way unique to him.”2 Vygotsky argued that language and cul-
ture were important elements in the acquisition of knowledge and that prior con-
structivist theories inadequately accounted for these elements. For Vygotsky,
learning was a social process and interactions with others were the core founda-
tion of knowledge acquisition.
In the acquisition of knowledge and skills, Vygotsky described two distinct devel-
opmental levels. The actual developmental level refers to the stage at which the
learner internally comprehends the material and is able to perform a task unas-
sisted. Of more importance to medical educators is the zone of proximal develop-
ment (ZPD). The ZPD is a stage where the learner requires assistance from a more
knowledgeable “other” (i.e. a teacher in broad terms). Essentially, the ZPD is the
43
intermediate region on a performance spectrum between what a learner CAN
perform without assistance and what the learner CANNOT perform even with
assistance. The ZPD defines the region on the spectrum where a learner CAN
perform WITH ASSISTANCE from a teacher. This is the developmental area
where learning occurs.
The concept of scaffolding becomes important when considering the ZPD. When
scaffolding a learner, the teacher provides enough assistance so that the learner is
able to push past the boundaries of their existing knowledge. Assistance is then
slowly withdrawn by the teacher so that the student can assume independence in
performing or understanding the task. Many medical educators already perform
scaffolding, whether or not they use the label. For example, when teaching a
skill, a teacher may initially demonstrate the skill at normal speed. Then, the
teacher deconstructs all of the steps of the skill. Next, the teacher performs the
skill while the learner describes the steps. Finally, the learner performs the skill.
A scaffold provides appropriate and safe boundaries for complex abilities, stretch-
ing the required performance of the learner as they develop their ability. As the
learner’s ability grows, support is withdrawn until the learner is able to function
independently.
In summary, social constructivism is an education theory that describes the inter-

action between active learning, coaching, and social interaction. Coined by the so-
ciologists Berger and Luckman, social constructivism focuses on the learner, not
on the material being taught.
Social constructivist models in medical education are represented in problem-

based learning, team-based learning and small group work (e.g., seminars). How-
ever, technological innovation has advanced and expanded the scope of this
learning theory. The most obvious example is the flipped classroom, where stu-
dents switch the lecture and homework components of a class. Recorded lectures
are reviewed asynchronously prior to class with class time spent engaging the
teacher and peers on the application of the knowledge (e.g., homework). The use
44
of multimedia technology allows a feasible and efficient delivery of the tradi-
tional lecture outside of the classroom, making space for interaction and experi-
mentation with the material within a group of peers.
In addition, there are digital platforms that facilitate group learning despite geo-
graphical barriers. Platforms like Slack and Google apps facilitate asynchronous
discussion and collaborative project work typical of the ZPD. Of course, the diffi-
culty with online platforms is encouraging true collaboration. These platforms
are less easy to facilitate for teachers and social norms for all members to contrib-
ute are not as strong. Nevertheless, the ability to virtually collaborate across mul-
tiple time zones expands the influence of social constructivism in modern educa-
tion.
While the small group sessions typical of resident conference (i.e. academic half
day) is an excellent example of leveraging social constructivism, the classic class-
room example is problem-based learning (PBL). PBL is widely adopted in medi-
cal schools, where small groups of students work together longitudinally, ad-
dressing a new clinical problem each week. For example, a group may work
through the diagnosis and management of a patient presentation suggestive of
gastrointestinal bleeding. An experienced facilitator scaffolds the issues to be ad-
dressed in the problem. Each group may achieve different learning outcomes
based on their specific learning needs or the way discussion and research un-
folds.
High fidelity simulation is another example of social constructivism in medical

education. Teams of learners are tasked to solve a simulated clinical presentation.
If the team includes learners at different stages, more experienced members can
scaffold support to the junior learners commensurate with their needs. This al-
lows the individual to draw on the experience of all members of the group to fa-
cilitate the internalization of their own learning.
45
1. Adams P. Exploring social constructivism: theories and practicalities. Education.

2006; 34(3): 243-257.  
This article is a comprehensive description of the principles of and rationale for social
constructivism. It describes the evolution of social constructivism from constructivist
theories. It is a must read for anyone wanting a deep dive into social constructivism.
2. Nalliah S, Idris N. Applying the learning theories to medical education: A

commentary. IeJSME. 2014; 8(1): 50-57.  
This article provides historical context for the development of social constructivism,
tracing the origin from the 1700s to present day. The major contributors to social
constructivist theory are profiled. Extra attention is paid to Vygotsky and to explaining
current thoughts on social constructivism and how it applies to modern education.
3. Kay D, Kibble J. Learning theories 101: application to everyday teaching and

scholarship. Adv Physiol Educ. 2016; 40: 17-25.  
This article is a great introduction to several different learning theories. For each learning
theory, the authors describe a teaching scenario that employs the learning theory, followed
by an explanation of the learning theory. Constructivism is contrasted with cognitivist
and behaviorist theories.
4. Dong C, Clapper T, Szyld D. A qualitative descriptive study of SimWars as a

meaningful instructional tool. International Journal of Medical Education.
2013; 4:139-145.  
This article is a qualitative study about the effectiveness of SimWars as an educational
modality. The group used social constructivism theory to create the interview questions.
The themes they identified centered around teamwork and debriefing concepts that rely
heavily on the collaborative nature of social constructivism.
46
LIMITATIONS OF THE THEORY
Social constructivism is dependent on social interactions between learners and

teachers. Therefore, disengaged or shy participants limit learning. Facilitators
must encourage all members to engage, while maintaining a safe and trusting
learning environment.
Additionally, the best groups are diverse in background. In a given group (e.g.
medical school class, clerkship group, or residency) members may be homoge-
nous, limiting the benefit of new insights from participants with different back-
grounds and experiences. Creative solutions such as incorporating inter-
professional learning may help promote diversity of perspective.
Social constructivism requires a marked change from traditional classroom teach-

ing, where the learners are passive recipients of instruction from a teacher. A
teacher not trained in the scaffold approach that supports the ZPD will inhibit en-
gagement, discovery, and incorporation of the material. Insistence on focusing on
what is taught, rather than what is learned, is counter to social constructivist the-
ory of learning. Finally, learning that is individualized can be challenging to as-
sess.

Mira felt like she was in over her head and decided to seek help. She had met some out-
standing medical educators at a recent academic conference and reached out for sugges-
tions. They recommended that she research different theories in medical education to see if
any of them provided inspiration.
Mira encountered many different theories during her research. She found many of them
appealing, but it was the theory of social constructivism that resounded with her the
most. She liked that social constructivism focused on working as a group and learning
from one another. If the residents could work on problems together, in groups, this could
alleviate some of their disengagement with the current design of the academic conference.

47
Another aspect of social constructivism that appealed to Mira was the concept of scaffold-
ing. She could deploy the senior residents as teachers, using them to scaffold the learning
of the junior residents.
Mira decided to put the theory into action. She reorganized the design of conference into a
problem-based learning curriculum. She formed small groups of residents stratified by
levels of training. Mira also increased the amount of team simulation sessions, again em-
ploying the group to teach each other. Mira re-surveyed the residents and found that satis-
faction with academic conference had increased, but now the residents wanted to discuss
some of the rotations they didn’t like...
REFERENCES
1. Adams P. Exploring social constructivism: theories and practicalities. Education. 2006; 34(3): 243-257.
2. Nalliah S, Idris N. Applying the learning theories to medical education: A commentary. IeJSME. 2014;
8(1): 50-57.
3. Kay D, Kibble J. Learning theories 101: application to everyday teaching and scholarship. Adv Physiol
Educ. 2016; 40: 17-25.  
48
CH APT E R 6
Reflective Practice
Authors: Jordan Spector, MD; Sara Krzyzaniak, MD; Lauren Wendell, MD 
Editor: " Jonathan Sherbino, MD, MEd 
A CASE
“That didn’t go well at all,” thought Jeffrey. He had just begun his third year of
emergency medicine (EM) residency training at University Medical Center, a Level I
trauma center, and was now responsible for leading the trauma resuscitations, alongside
the Center’s trauma surgeons. He was removing his gown and gloves, and reflecting on
the patient that he had just cared for, wondering why he felt the case went poorly.
Jeffrey had prepared for the case after receiving prehospital notification from paramedics.
He had run through possible interventions with his attending, readied his equipment at
the bedside, and positioned himself at the head of the stretcher prior to patient arrival. The
patient was a young man with a gunshot wound to the thorax, presenting with
hypotension. Unfortunately, the trauma room became chaotic the moment the patient
arrived. Multiple providers were shouting orders, even before the paramedics could
provide a history or the patient had been transferred to the emergency department (ED)
stretcher. The ED pharmacist acted on the first order he received for opiate analgesia, but
she did not hear the other requests for antibiotics. The charting nurse shouted multiple
times for the blood pressure value, clearly unable to hear the response that Jeffrey
provided. The EM and surgical staff argued for a short spell whether the patient needed to
be emergently intubated. Once the decision was made in favor of intubation, Jeffrey was
given approximately 60 seconds to attempt the procedure, only to be bumped out of place
by an anesthesiologist. “The trauma room is no place to learn a procedure for the first
49
time!” stated the trauma attending. The surgeons had no idea that Jeffrey had, in fact,
performed numerous intubations in the past. After the patient was stabilized, the ED
staff began to wheel the patient to the radiology suite for advanced imaging, only to have
the senior surgical resident scream “I told you he’s too unstable for CT, we’re taking him
to the OR! Are you deaf?”
Jeffrey was asked to stay around after the case, as the charting nurse was unable to hear
any elements of Jeffrey’s primary and secondary survey. The senior nurse in the trauma
room (who had been practicing at the center for 25 years) told Jeffrey “you need to do a
better job keeping control of the room.” Jeffrey was so demoralized he was unsure if he
could complete the rest of his shift.
• If you were advising Jeffrey, what would you suggest that he do?
50
OVERVIEW | REFLECTIVE PRACTICE
Reflection or reflective practice is a theory of knowledge acquisition predicated
on the belief that learning occurs through deliberate and comprehensive thinking
about a schema or activity, both during and after the performance of that activity.
1 Most descriptions of reflective practice postulate that a learner considers and
reflects on a need or a problem when she or he encounters a new practice or

unexpected difficulty with a familiar practice.2 Reflective practice supports a
constructivist epistemology of knowledge (i.e., theory of learning that suggests
that new knowledge is integrated and interpreted based on past experience and
learning), as the learner often has predisposed attitudes and knowledge that
directly influences that individual’s experience (i.e. interpretation) with a
learning opportunity.3 Finally, some models of reflective practice stress that
reflection may occur both during and after an activity.
Reflective practice is fundamentally an iterative process with thoughts that drive

action during an activity and the consideration of elements of the activity after
the fact, informing future performance of the activity.2 These inter- and post-
performance cognitive process yield learning and knowledge. (See Figure below)
51
• John Dewey
• David Kolb
• Donald Schön

Terry Borton 
Kevin Eva 
Graham Gibbs 
Karen Mann 
Glenn Regher
BACKGROUND
The theory of reflection as a fundamental skill for learning first arose from the
writings of John Dewey, who defined reflection as “active, persistent and careful
consideration of any belief or supposed form of knowledge in the light of the
grounds that support it and the further conclusive to which it tends.”2 In his
book “Reach, Touch and Teach”, Terry Borton built upon Dewey’s thesis when he
described a simple iterative cycle of learning, coining the phrase, “What, so what,
and now what?”4 In this model, the ‘what’ is the new activity or experience, the
‘so what’ is the rational, cognitive examination of the experience that just oc-
curred, and the ‘now what’ is the manner by which the learner incorporates the
results of their cognitive analysis into future action.4
Donald Schön became a thought leader of reflective practice when he described a

knowledge cycle predicated on education and expertise that occurs both con-
sciously and subconsciously during activity. Consistent with other theorists in
the field, Schön’s description is learner-centric; it is through the step-wise progres-
sion of thoughts and impressions that a learner develops knowledge with little
influence from the teacher. Schön posited that the approach an individual em-
ploys when addressing a particular problem arises from both the learning that oc-
curred during the performance of that action, as well as the processing of prob-
52
lems, solutions, and outcomes after the fact.5 Schön described a reflective loop,
wherein the individual performs an action (knowing-in-action), but may encoun-
ter a stimulus outside of their expertise (i.e. a surprise). A skilled individual may
be able to improvise or think on their feet to attend to the problem directly, per-
haps through experimentation. After the new experience, the individual may en-
gage in reflection-on-action, a post-hoc analysis of actions, reactions and conse-
quences. This latter reflection reinforces knowledge and is a key element in de-
veloping mastery or expertise.6
A contemporary of Schön, David Kolb described a cyclical theory of experiential

learning. Kolb states that a learner may have or participate in a concrete experi-
ence. After this, the individual engages in reflective observation, reviewing the
concrete experience. Next, the learner engages in abstract conceptualization,
where the reflection gives rise to new ideas or schemata or modification of a pre-
vious concept. Finally, the learner will employ active experimentation, applying
the new ideas to the world around them and utilizing the new approach in subse-
quent concrete experiences.7
Graham Gibbs built upon previous theories and described his own reflective cy-
cle to describe growth and development in the learner.8 His highly intuitive
learning cycle model provides the learner with cue questions based on integral
concepts to be examined after a new activity. The steps of Gibbs’ cycle8 include:
1. Description (objective review of events without editorial),
2. Feelings (how the events influenced the emotional state of the learner),
3. Evaluation (what did or did not go well with the event, subjective judgements)
4. Analysis (global impression of the events within the context of other knowl-
edge and experience)
5. Conclusion (how best to frame the events, evaluating what could have been
done or avoided)
6. Action plan (what to do in analogous situations in the future to improve cir-

cumstances and outcomes)
53
Recent publications have tried to align reflective practice and experiential learn-
ing, where similar concepts are related and overlap. As quoted in Jennifer
Moon’s book, “transforming experiential and tacit knowledge into principled explicit
knowledge about teaching requires intentional reflection for the purpose of making sense
of and learning from experience, for the purpose of improvement…reflection requires link-
ing existing knowledge to an analysis of the relationship between current experience and
future action…reflection aids in the reflective processes themselves, thereby building and
expanding knowledge.”9
The implementation of reflective practice has recently gained favor in medical

education. In a systematic review on the practice of reflection in the education of
healthcare professionals, Mann and colleagues identified multiple studies that
suggest that reflective practice is a key practice for health professionals.2 Reflec-
tion appears to be a useful approach for learners to make sense of complicated
situations, as frequently occurs in the realm of patient care. The process appears
to be stimulated by complex scenarios, though variably utilized, depending on
the individual.2 Reflection can be a skill that is developed over time and put to
use in various contexts. Multiple studies demonstrate that healthcare profession-
als use processes that resemble reflection in action and reflection on action dur-
ing patient care.2 Mann argues that reflection may be most useful when viewed
as a learning strategy to “assist learners to connect and integrate new learning with ex-
isting knowledge and skills.”2 Reflection may not be an explicit learning tool for
novices. However, it can be modeled by experienced practitioners and taught to
junior learners as a means to assess their state of knowledge, to identify strengths
and weaknesses, and to improve the learning environment in subsequent
iterations.2
Reflective practice has been used with medical students,2,5 nursing profession-
als,10 and pharmacy professionals.11 In one study, Gibb’s reflective cycle was
used to optimize learning in a simulation curriculum.8 In the classroom, reflec-
54
tive writing is a practice that has shown to be of benefit to medical students and
residents seeking to cultivate empathy, resilience, and wellness.
The learner-centric nature of reflective practice necessitates an engaged learner.

As this practice may be novel to some learners, appropriate instruction and fram-
ing is critical to its success. It is important that learners see this as not ‘just an-
other assignment’, but as an integral component to their ongoing growth.
Eva and Regehr suggest that cognitive, sociobiological and social factors limit an
individual’s insight into their own performance and abilities. This impairs accu-
rate, summative, self-assessment required for reflection. As the authors state,
“personal, unguided reflections on practice simply do not provide the information suffi-
cient to guide performance improvements.”12 In essence, reflection requires pedagogi-
cal oversight and feedback from an expert or mentor, a process Eva and Regehr
term ‘self-directed assessment seeking.’12
55
1. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health

professions education: a systematic review. Adv Health Sci Educ Theory Pract.
2009;14(4):595-621. doi:10.1007/s10459-007-9090-2. 
This systematic review introduces a number of theories about the concept and utility of
reflective practice. It makes manifest the inherently iterative process of reflection,
comparing and contrasting different theories from different thought leaders within the
field. Most significantly, this review highlights references from the medical and medical
education literature that apply reflective practice to healthcare education.
2. Eikeland Husebø S, Nestel D. Theory for Simulation Reflective Practice and Its
Role in Simulation. Clin Simul Nurs. 2015;11(8):368-375. doi:10.1016/j.ecns.
2015.04.005. 
This pair of authors provide a clear, concise review of reflective practice and relevant key
theories. The authors examine multiple conceptions of reflection, using Gibbs’ reflective
cycle to translate the different steps of reflection to learning via simulation.
3. Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med
Teach. 2009 Aug;31(8):685-95. 
This comprehensive narrative review makes practical connections for frontline teachers
between the psychological frameworks that support reflection and the implications for
medical education. Issues covered include: reflection for learning, reflection to develop
therapeutic relationships, reflection to develop professional practice, guided reflection,
ethical aspects of reflection, and educational strategies to develop reflection, among others.
56
Jeffrey spoke with a number of peers, and realized he was not alone in having a sense that
the trauma room was more disorganized and stressful than he had anticipated. After re-
flecting on the circumstances that took place in a number of recent trauma resuscitations,
it became clear that interdisciplinary communication between the EM and trauma attend-
ings needed to improve. It was Jeffrey who argued that a lack of communication in the
trauma bay would not improve until there was substantive interdisciplinary communica-
tion outside the trauma bay. He felt that all providers would function better if they could
mutually agree on the optimal organization of care (e.g., who performs the primary and
secondary surveys, who calls out orders, etc.) With the support of his EM program direc-
tor, Jeffrey conceived and organized the EM-Surgery Collaboration Committee with meet-
ings every four months to address issues and concerns related to the care of trauma pa-
tients. During these meetings, representatives from the clinical services were able to re-
flect on the challenges they perceived when working together and how to improve team
performance. For example, Jeffrey learned that the surgeons did not know that EM resi-
dents had sufficient training in airway management prior to taking on the role of trauma
team leader. Both services cited the desire for a singular voice leading the resuscitation -
calling out information and making orders. Both groups cited a desire for a trauma resus-
citation with less noise pollution. In effect, Jeffrey promoted reflective observation of
the care of trauma patients among all stakeholders. This lead to a shared abstract concep-
tualization of optimal trauma patient care, thereby improving knowledge-in-action in
the care of future trauma patients.
57
REFERENCES
1. Sellars M. Chapter 1 : Reflective Practice. In: Reflective Practice for Teachers. SAGE Publications Ltd;
2013:1-21.
2. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a
systematic review. Adv Health Sci Educ Theory Pract. 2009;14(4):595-621.
3. Boud D, Walker D. Making the most of experience. Stud Contin Educ. 1990;12(2):61-80.
4. Borton T. Applying The Process Approach. Reach Teach Touch. 1970.
5. Slotnick HB. How doctors learn: the role of clinical problems across the medical school-to-practice con-
tinuum. Acad Med. 1996;71(1):28-34.
6. Borduas F, Gagnon R, Lacoursière Y, Laprise R. The longitudinal case study: from Schön’s model to
self-directed learning. J Contin Educ Health Prof. 2001;21(2):103-109.
7. McLeod SA. Kolb - Learning Styles. www.simplypsychology.org/learning-kolb.html. Published 2013.

Accessed January 1, 2016.
8. Eikeland Husebø S, Nestel D. Theory for Simulation Reflective Practice and Its Role in Simulation.
Clin Simul Nurs. 2015;11(8):368-375.
9. Moon JA. A Handbook of Reflective and Experiential Learning Theory and Practice. London and New
York: RoutledgeFalmer Taylor & Francis Group; 2004.
10.Jacobs S. Reflective learning, reflective practice. Nursing (Lond). 2016;46(5):62-64.
11.Plaza CM, Draugalis JR, Slack MK, Skrepnek GH, Sauer KA. Use of reflective portfolios in health sci-
ences education. Am J Pharm Educ. 2007;71(2):34.
12.Eva KW, Regehr G. “I’ll Never Play Professional Football” and Other Fallacies of Self-Assessment. J
of Continuing Education. 2008; 28(1):14–19. 
58
CH APT E R 7
Self-Directed Learning
Authors: Jenna Fredette, MD; Cathy Grossman, MD, CHSE; Joe Walter MD 
Editor: Megan Boysen-Osborn, MD, MHPE 
A CASE
Joe was an eager learner. He maintained 90% didactic conference attendance, always
completed the weekly textbook assignments, and showed up to his shifts on time. He got
along with the nurses and faculty. Everyone enjoyed working with Joe.
While Joe’s assessments in the areas of professionalism and interpersonal communication

were always outstanding, his marks in medical knowledge and patient care were just
average. Joe was disappointed to learn that he had only scored in the 30th percentile on
his annual in-training examination.
He met with his program director (PD) to brainstorm for ways to improve his medical
knowledge and in-training examination scores. His PD told him, “You’re doing
everything right Joe! You always show up to conference and get 100% on the weekly
reading quizzes!” Joe knew he was doing everything “right,” but he was frustrated by his
results.
Every Wednesday, he sat through the same series of lectures he had experienced during
the last three years of his residency. Sometimes, he was even able to predict which slide
was coming next! Joe participated in all of the required residency activities and felt like he
knew everything. However, despite knowing everything at conference, he felt like he
didn’t know anything when he was working clinically. He was often stumped, not
59
knowing which test to order next or what the diagnosis was. He felt even worse when he
received his in-training exam results.
Joe showed up to work one day and became very frustrated that he didn’t even know what
medication to use for a patient requiring procedural sedation. Joe decided to ask one of his
friends from the anesthesia residency program for advice.
• What would you advise Joe to do in order to increase his medical knowledge?
60
OVERVIEW | SELF-DIRECTED LEARNING
In the setting of rapidly evolving knowledge, Malcolm Knowles argues that the
main purpose of education is to provide learners with the “skills of inquiry”
rather than the knowledge itself. Knowles offers self-directed learning (SDL) as
an essential skill to maintain human competence.1
Self-directed learning occurs when learners perform the following actions1:

1. Take initiative to diagnose their learning needs, with or without the help of
others
2. Formulate learning goals
3. Identify human and material resources for learning
4. Choose and implement appropriate learning strategies
5. Evaluate learning outcomes
A similar definition for SDL, offered by Hiemstra, is any study form in which
individuals have primary responsibility for planning, implementing, and
evaluating the effort.2" " " " " "
Knowles distinguishes SDL from traditional teacher-directed learning on several

bases. Self-directed learners’ internal motivation for learning develops from life
tasks or problems.1 Learning is problem-centered, rather than subject centered.1
Knowles emphasizes that the learner’s motivation is an essential feature of SDL;
self-directed learners may benefit from teacher-centered learning, but the self-
directed learner enters the experience with a different fundamental attitude.1 In
general, however, the role of the teacher in SDL is to dialogue with learners,
secure resources, evaluate outcomes, and promote critical thinking.2
The first parts of SDL, “diagnosing” one’s learning needs and formulating
learning goals, requires a learner to assess their personal knowledge deficits (i.e.
the difference between the desired skills and knowledge and their current skills
and knowledge).1 Therefore, self-assessment is a key concept when discussing
SDL.
61
Malcolm Knowles
• Knowles MS. Self-directed learning: A guide for learners and teachers. New
York, NY: Cambridge, the Adult Education Company, 1975.
Allen Tough
• Tough AM. Learning without a teacher. Toronto: Ontario Institute for
Studies in Education. The adult's learning projects: A fresh approach to
theory and practice in adult learning. Austin, TX: Learning Concepts, 1967.

Brockett & Hiemstra
• Brockett RG, and Hiemstra R.. Self-direction in Adult Learning:
Perspectives on Theory, Research and Practice. London: Routledge, 1991.
Rosemary S. Caffarella
• Caffarella RS, O'Donnell JM. Self-directed learning. Nottingham:
Department of Adult Education, University of Nottingham, 1989.
• Merriam SB, Caffarella RS. Learning in adulthood. San Francisco and
Oxford: Jossey-Bass Publishers, 1991.
Philip C. Candy
• Candy PC. Self-Direction for Lifelong Learning. A Comprehensive Guide to
Theory and Practice. San Francisco, CA: Jossey-Bass, 1991.
Gerald O. Grow
• Grow GO. Teaching learners to be self-directed. Adult Education Quarterly,
1991;41, 125- 149.
62
BACKGROUND
Some of the concepts inherent to self-directed learning (SDL) have existed for cen-
turies, with “self-study” being an important concept in the learning of Socrates,
Plato, Aristotle, Alexander the Great, Caesar, Erasmus, and Descartes.2
In the 1920s, Lindeman laid the foundation for many of the core elements of self-
directed learning.3 Rather than SDL, Lindeman refers to these elements in the con-
text of ‘Adult Education’. Lindeman makes several assumptions in his work, in-
cluding that adults are ‘self-directing’ and are motivated by “needs and interests
that learning will satisfy.”3,4
In 1961, Houle performed a study of 22 subjects and divided each into sub-
groups, one being the learning-oriented learners who “make decisions in life in
terms of the potential for growth which they offer.”5 Knowles and others feel that
the discovery of learning-oriented learners was an important concept in the dis-
covery of self-directed learners.4
Carl Rogers offered the concept of student-centered learning in 1969, with the ob-
servations that “the sense of discovery...and comprehending [associated with learning]
comes from within.”6,7 The learner evaluates “whether [the learning] leads toward
what he wants to know.”6,7 In 1971, Tough observed that the majority of learning
projects are “planned by the learner himself, who seeks help and subject matter
from a variety of acquaintances, experts, and printed resources.”8
In 1973, Malcolm Knowles laid the foundation for his future work on SDL with
his book The Adult Learner: A Neglected Species.4 Here, he popularized the term ‘an-
dragogy’ to refer to the concepts and assumptions inherent to the education of
adult learners. In this work, he describes a mature learner’s desire to be self-
directing, identifying one’s own readiness to learn and organizing learning
around life problems (motivations).4 He also emphasizes the need for lifelong
education to maintain competence. He describes the skills of lifelong learning,
many of which parallel the fundamentals of SDL. A more formalized definition
for of SDL emerged in 1975 when Knowles published a book entitled Self-directed
learning: A guide for teacher and learners.1
63
In 1977, Lucy Guglielmino developed a Self-Directed Learning Readiness Scale
(SDLRS), a self-report Likert scale to measure one’s readiness for SDL.9 Addition-
ally, Oddi developed a 24-item continuous learning inventory.10 These two instru-
ments have been widely used in many future studies on SDL.
As the concept of SDL evolved, several authors offered further contributions (in-
cluding Brockett, Hiemstra, Long, Candy, Caffarella, O’Donnell, Grow, and
Merriam).11-17 For example, Grow theorizes that a learners mature through stages
to ultimately become a self-directed.14 During the first stage, the learner is com-
pletely dependent on the teacher for learning and in the last (fourth) stage, a
learner is a master of SDL. Other authors provide conceptual models for SDL.
For example, the Brockett and Hiemstra provide a conceptual framework for
SDL, distinguishing between SDL (e.g. instructional method processes) and
learner self-direction (e.g. personality characteristics) in their Personal Responsibil-
ity Orientation (PRO) model.11
Knowledge has grown exponentially over the last century. As early as 1930, Al-
fred North Whitehead stated that “we are living in the first period of human history
for which [the] assumption [that major cultural changes take longer than a lifespan] is
false...today this time-span is considerably shorter than that of human life.”4 This idea
rings even more true in the current era of technology and information sharing.
One of the core fundamentals of SDL is that learners “identify human and material
sources for learning.”1 While this action could have been difficult to achieve before
the widespread dissemination of textbooks and online resources, the current envi-
ronment is one rich with human (albeit virtual) and material sources for learning.
Learners have a variety of open access journals, digital textbooks, blogs, pod-
casts, free open access medical education (FOAM), and massive open online
courses (MOOCs).18-22 Thus, the fundamentals of SDL are extremely well-suited
for the modern era.
Within medicine, guidelines for SDL are present at all stages. Continuing medical
education relies upon motivated self-directed learners to maintain competence
64
within the health care system. Undergraduate and graduate medical education
programs require curricula to ensure that learners are self-directed. The Liaison
Committee for Medical Education (LCME) standard 6.3 states:
The medical curriculum [should include] self-directed learning experiences and

time for independent study to allow medical students to develop the skills of lifelong
learning. Self-directed learning involves medical students’ self-assessment of learn-
ing needs; independent identification, analysis, and synthesis of relevant informa-
tion; and appraisal of the credibility of information sources.23
Many medical schools meet this requirement in the form of problem-based learn-
ing (PBL). PBL engages learners in many of the fundamentals of SDL. According
to Barrows, PBL encourages students to “improve on their knowledge base to keep con-
temporary in their eventual field of medicine and to provide appropriate care for new or
unique problems they may face in their work. This is self-directed learning.”24,25
Within graduate medical education, the need for SDL is found within the Accredi-
tation Council for Graduate Medical Education (ACGME) core competency: prac-
tice based learning and improvement (PBLI). PBLI requires that residents “demon-
strate the ability to investigate and evaluate their care of patients, appraise and assimilate
scientific evidence, and continuously improve patient care based on constant self-
evaluation and life-long learning.”26
The ACGME allows emergency medicine residencies to provide up to 20% of di-

dactic education in the form of ‘individualized interactive instruction’, a term pre-
viously referred to as ‘asynchronous learning’. While asynchronous learning is
not synonymous with SDL, many of the components of SDL are necessary for suc-
cessful participation in asynchronous curricula.26
Individualized interactive instruction (III) is more rigorous than the catchall term
‘asynchronous learning’, which literally means that the learning occurs asynchro-
nously. Individualized interactive instruction requires that the learning activity is
monitored for resident participation, overseen by faculty, monitored for effective-
65
ness, and has an evaluative component.27 Asynchronous and III curricula are best
carried out with the use of a learning management system (LMS), such as Black-
board, Schoology, or Canvas. An LMS can organize and curate resources for learn-
ers, as well as provide a platform for self-assessment and discussion among learn-
ers. However, if the instructor is choosing the instructional strategies and learn-
ing resources, then such asynchronous learning is not really ‘self-directed’.
An important question in the context of SDL is how learners should identify the
appropriate human and material resources for learning. In the era of teacher-
centered instruction, a student had to trust the instructor as the reputable infor-
mation source. With the current abundance of materials available to learners, it
may be difficult to distinguish between credible and inaccurate materials. Re-
sources such as the Academic Life in Emergency Medicine (ALiEM) Approved In-
structional Resources (AIR) review content to ensure accuracy and provide a
‘stamp’ of approval.28
Inherent to the SDL process is the ability to perform accurate self-assessment.

Norman, Eva, and Regehr report that humans are inherently poor at this skill of
self-assessment, bringing this construct of SDL into question.29-33 One’s own per-
ceptions of one’s knowledge and skills are fraught with the ‘Lake Wobegon ef-
fect’ (from Garrison Keillor fictional town about a community where everyone be-
lieves themselves to be ‘above average’).34 Dunning and Kruger suggest that a
person's incompetence masks his/her ability to recognize his/her own
incompetence.29
Intriguingly there is no one accepted definition of self-assessment, as it means

many different things to different people. Per a systematic review on self-
assessment, the definitions of “self-assessment” were not available in most stud-
ies, with the majority of studies set out to determine the ‘accuracy’ of self-
assessment in terms of quantitative comparisons with external measures or ‘ex-
pert’ ratings.35
66
Eva and Regehr take the definition of self-assessment into a broader territory
than just an ‘ability’ by splitting this idea into three separate pedagogical
strategies.33
1. Self-directed assessment seeking: Using data from invited feedback and other
external sources to direct personal improvement.
2. Reflection: Deliberate exploration of elaborating one’s understanding of the

problem one has or is facing rather than simply trying to solve it (i.e. trying to
understand why a clinical case went the way it did).33
3. Self-monitoring: Personal judgment of one's ability versus awareness, in the

moment, of whether or not the current situation is going well; “slowing down
when one should” or “knowing when to look something up” or “knowing
when to ask for help.”33
Self-directed learning also requires that learners formulate their own learning
goals; this idea is also fraught with difficulty. Norman argues that learners, espe-
cially in medical education, must have significant guidance on what to learn;
learners may still successfully choose how they learn it (i.e. directed,
self-learning).30
67
1. Knowles MS. Self-directed learning: A guide for learners and teachers. New
York, NY: Cambridge, the Adult Education Company, 1975. 
Regarded by many as the original major contribution to self-directed learning, Knowles
describes the fundamentals of self-directed learning and distinguishes between teacher-
directed and self-directed learning.
2. Tough A. The Adult's Learning Projects: A Fresh Approach to Theory and

Practice in Adult Learning. Toronto: OISE, 1971. 
Tough interviewed over 50 individuals from many different social classes. He determined
that the average person completes approximately 8 learning projects per year, totaling
700-800 hours, with the majority of these projects being chosen by the learner themselves.
3. Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med
Teach. 2009 Aug;31(8):685-95. 
This comprehensive narrative review makes practical connections for frontline teachers
between the psychological frameworks that support reflection and the implications for
medical education. Issues covered include: reflection for learning, reflection to develop
therapeutic relationships, reflection to develop professional practice, guided reflection,
ethical aspects of reflection and educational strategies to develop reflection, among others.
4. Houle CO. The inquiring mind. Madison: University of Wisconsin Press, 1961.  
Houle performed a study of 22 subjects. He determined that the subjects fell into three
categories: goal-oriented, activity-oriented, and learning-oriented. The latter group
provided some basis for self-directed learning.
68
Joe met with Katie, a third-year resident in the anesthesia program. Katie told Joe that she
had felt the same way over the past two years. This year, however, her PD started a self-
directed learning curriculum during the last hour of conference. Residents were in-
structed to write down a clinical question they had during the week prior to conference.
They would bring the question to conference and would be given time to research the lit-
erature for guidance in answering it.
Ever since introducing this curriculum, Katie felt much more confident during her shifts.
Initially she felt so overwhelmed by all of the knowledge out there, but since then she felt
more comfortable in finding the right places to look for answers.
Joe was excited to bring this idea back to his PD in emergency medicine. He scheduled a
meeting for the Wednesday after conference. His program director loved the idea, but
wanted to make sure it would count for conference credit.
Joe looked on the emergency medicine Council of Residency Directors (CORD) website
and found that the activity may have qualified for individualized interactive instruction.
Joe learned that if the activity is monitored for participation, overseen by the faculty,
monitored for efficacy, and has an evaluative component it would qualify. Joe knew that
the first two parts were easy to achieve, but didn’t know how he will accomplish the last
two. Joe and his PD met again and decided to include a question about the new confer-
ence component on the annual program evaluation (APE). The program director also
planned to review and evaluate all of the residents’ clinical question worksheets.
Joe couldn’t wait to tell his colleagues about the new conference addition!
69
REFERENCES
1. Knowles MS. Self-directed learning: A guide for learners and teachers. New York, NY: Cambridge,
the Adult Education Company, 1975.
2. Hiemstra R. Self-directed learning. In: T. Husen & T. N. Postlethwaite (Eds.), The International Ency-
clopedia of Education (second edition), Oxford,: Pergamon Press, 1994.
3. Lindeman EC. The Meaning of Adult Education. New York, NY: New Republic, 1926.
4. Knowles M. The Adult Learner: A Neglected Species. Houston, TX. Gulf Publishing Company, 1973.
5. Houle CO. The inquiring mind. Madison: University of Wisconsin Press, 1961.
6. Rogers CR. Freedom to Learn. Columbus, OH: Merrill, 1969.
7. Weibell CJ. Principles of learning: 7 principles to guide personalized, student-centered learning in the
technology-enhanced, blended learning environment, 2011. Retrieved December 15, 2016 from
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9. Guglielmino LM. Development of the Self-Directed Learning Readiness Scale. (Doctoral dissertation,
University of Georgia, 1977). Dissertation Abstracts International, 38, 6467.
10. Oddi L. Development and validation of an instrument to identify self-directed continuing learners.
Adult Education Quarterly. 1986;36(2), 97-107,
11. Brockett RG, Hiemstra R. Self-direction in Adult Learning: Perspectives on Theory, Research and Prac-
tice. London: Routledge, 1991.
12. Caffarella RS, O’Donnell JM. Self-directed learning. Nottingham: Department of Adult Education,
University of Nottingham, 1989.
13. Candy PCSelf-Direction for Lifelong Learning. A Comprehensive Guide to Theory and Practice. San
Francisco, CA: Jossey-Bass, 1991.
14. Grow GO. Teaching learners to be self-directed. Adult Education Quarterly, 1991;41, 125- 149.d
15. Long HB and Associates.. Self-directed learning: Application and theory. Athens, GA: University of
Georgia, Department of Adult Education, 1988.
16. Long HB. Oklahoma Research Center for Continuing Professional and Higher Education & North
American Symposium on Adult Self-Directed Learning. Self-directed learning: Emerging theory &
practice. Norman, OK: Oklahoma Research Center for Continuing Professional and Higher Educa-
tion, University of Oklahoma, 1989.
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17. Merriam SB, Caffarella RS. Learning in adulthood. San Francisco and Oxford: Jossey-Bass Publishers,
1991.
18. Kellogg S. Online learning, how to make a MOOC. Nature. 2013;499(7458):369-71.
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ture of medical and nursing education? Am J Crit Care. 2016;25(1):93-6. doi: 10.4037/ajcc2016622.
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May;8(2):219-25.
29. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incom-
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30. Norman GR. The adult learner: a mythical species. Acad Med. 1999;74(8).
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York Times. 2010 Jun;20. Accessed June 4, 2016. Available at available at this link.
32. Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda.
Acad Med J Assoc Am Med Coll. 2005;80(10 Suppl):S46-S54.
71
33. Eva KW, Regehr G. “I’ll never play professional football” and other fallacies of self-assessment. J Con-
tin Educ Health Prof. 2008;28(1):14-19.
34. Are ALL Minnesotans Above Average? - Science Friday. (2015) Accessed June 4, 2016. Available at this
link.
35. Colthart, I., Bagnall, G., and Evans, A, et al. (2008) The effectiveness of self-assessment on the identifi-
cation of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Med
Teach. 30(2):124-145.
72
CH APT E R 8
Bloom’s Taxonomy
Authors: Aaron Brown, MD; Nicolas Pineda, MD; Christopher Sampson, MD 
Editor: " Megan Boysen-Osborn, MD, MHPE 
A CASE
It was July. Richard, an intern, was excited to be starting in the Emergency Department.
“I really hope I get to intubate a patient today,” he stated to his attending Dr. French.
Dr. French then asked Richard about the indications for intubation. Richard responded,
“When they can’t breathe, you just stick the tube in!”
Dr. French saw that Richard was excited about the opportunity to intubate the patient,
but he was unable to assess, based on his question, whether Richard truly did not
understand the indications for intubation or whether he simply gave an excited response.
After further questioning, he determined that Richard could recite some of the indications
for intubation, but he could not adequately apply them to patient scenarios.
Dr. French had seen this same situation each academic year. He knew that Richard had
just completed an airway workshop during intern orientation. Dr. French decided that he
should review the airway workshop curriculum to determine if it could be improved.
Dr. French found that much of the current curriculum focused on the motor skills
required for intubating and the “difficult airway” algorithm. Dr. French was unable to
find any actual learning objectives for the current airway course. The curriculum had a
didactic lecture, which reviewed the indications for intubation at the beginning of the
workshop. The workshop also included a multiple choice question (MCQ) post-workshop
73
test that also included questions on the indications for intubation. Dr. French knew that
all the interns passed the MCQ test.
Dr. French couldn’t put his finger on why Richard was not performing as well as he
would like. He wondered how he could revise the current airway course to produce a more
skilled intern.
• Why is Richard not performing as well as he should?
74
OVERVIEW | BLOOM’S TAXONOMY
Bloom’s Taxonomy is a theoretical framework authored by Benjamin S. Bloom

and colleagues in the 1950s as a means of organizing and classifying higher
education learning objectives and assessment.1 It serves as one of several
conceptual frameworks for the acquisition of knowledge and skills.
When one discusses Bloom’s taxonomy, he or she is usually referring to the

taxonomy for the original, knowledge-based, cognitive domain. Bloom and
colleagues classified this domain into six hierarchical categories. The original
cognitive taxonomy has evolved over time. Anderson2 proposed the following
hierarchical order in 2001:
1. Remembering: Ability to recall facts

2. Understanding: Demonstrating comprehension
3. Applying: Application on knowledge to new tasks
4. Analyzing: The ability to separate a concept into its components and better
understand Its organization and structure
5. Evaluating: Judging the merits of ideas and components
6. Synthesizing/Creating: creating new structures/ideas from the parts of others
learned
Krathwohl (1964)3, Harrow (1972)4, and Simpson (1972)5 later published

additional taxonomies for the affective/emotional and psychomotor domains.
Benjamin S. Bloom
• Bloom, B.S. (1956). Taxonomy of Educational Objectives; the Classification of
Educational Goals,. New York: Longmans, Green; 1956.
75
David R. Krathwohl (The Affective Domain)
• Krathwohl DR. A revision of Bloom's taxonomy: An overview. Theory into
practice. 2002 Nov 1;41(4):212-8.
• Krathwohl DR, Bloom B, Masia B. Taxonomy of Educational Objectives: The
Classification of Educational Goals - Handbook II: Affective Domain. New
York: David McKay Company, 1964.
• Anderson LW, Krathwohl DR. A taxonomy for learning, teaching, and
assessing: A revision of Bloom’s taxonomy of educational objectives. New
York, NY: Longman, 2001.
R.H. Dave (The Psychomotor Domain)

• Dave RH. Developing and Writing Behavioural Objectives. (R.J. Armstrong,
ed.) Educational Innovators Press, 1975. 
Anita Harrow (Taxonomy of the Psychomotor Domain)

• Harrow AA. Taxonomy of The Psychomotor Domain: A Guide for Developing
Behavior. London: Longman, 1972.
E. J. Simpson
• Simpson EJ. The Classification of Educational Objectives in the Psychomotor
Domain. Education. 1972;3(3):43-56.
George E. Miller (Miller’s Pyramid)

• Miller GE. The Assessment of Clinical Skills/Competence/Performance. Acad
Med 1990;65(9):S63-S67. 
BACKGROUND
Bloom’s Taxonomy is not the sole work of Benjamin Bloom. It is the result of a se-
ries of higher educational conferences that focused on improving communication
of and structure for educational objectives and assessments. The taxonomy estab-
lished a hierarchy that included more advanced higher-order learning objectives
and goals beyond the basics of understanding and remembering.
76
The original taxonomy, published in Bloom’s 1956 work Taxonomy of Educa-
tional Objectives, included the following categories, in the following order:
knowledge, comprehension, application, analysis, synthesis, and evaluation.
Since this original work, Bloom’s colleagues, students, and others have devel-
oped several revisions of the taxonomy. As described in the Overview, Anderson
and Krathwohl published the currently used taxonomy, in 2001.2
In addition, both affective and psychomotor taxonomies have been added. The
original working group responsible for the cognitive objectives in 1956 devel-
oped the affective/emotional hierarchical categories. The affective hierarchical
taxonomy3 is as follows:
1. Receiving: Acknowledge and attention to knowledge
2. Responding: Interact with learning environment in an appropriate manner
3. Valuing: Apply worth or value to specific components learned
4. Organizing: Prioritize, compare, and evaluate a topic resulting in organization
5. Characterizing (Internalizing): The ability to use organized value systems to

create a pattern of behavior
The final addition was a psychomotor objectives taxonomy. Publications from the
original conference did not include this taxonomy, due to a lack of focus on
skills-based education. There are several published versions of psychomotor tax-
onomies, each differing slightly, but the taxonomy published by Simpson5 in-
cluded the following classifications where the learner displays the following:
1. Perception: Adjust behavior in response to environmental/external clues
2. Set (emotional/physical readiness): Demonstrate the willingness and readi-

ness to learn
3. Guided response: Perform a trained response to stimuli often previously dem-

onstrated for the learner
4. Mechanism: Perform habitual and learned responses proficiently
77
5. Complex overt response: Display expert proficiency in terms and/or speed
and/or quality of a task or act with perception during performance of the qual-
ity
6. Adaptation: Adapt easily made in specific situations because learner has famili-
arity with the task
7. Origination: Creation of new movements or techniques. This usually occurs

when learners have mastery of the task, which allows them to create new
movements and create new routines, teaching programs, and designs
Harrow (1972)4 and Dave (1975)6 also developed taxonomies for psychomotor ob-
jectives. Bloom’s taxonomy is one of several frameworks to guide educators in
creating learning objectives for an educational endeavor. The taxonomy provides
an important framework for creating tiered objectives within the cognitive, affec-
tive, and psychomotor realms of an educational project. The focus on a hierarchy
of goals supports the creation of goals for learners at different levels or evolving
learners. Many publications have produced a set of action verbs associated with
each level to be used when creating educational objectives. This facilitates the
creation of appropriate goals for each level within a given taxonomy by using the
appropriate action verbs.
Over time there have been many different interpretations of the original cogni-
tive taxonomy proposed by Bloom in 1956. Anderson and Krathwohl published
the most significant and accepted revisions in 2001.2 Anderson was a student of
Bloom’s and Krathwohl was one of the authors of the original work. The key dif-
ferences between the original and modern taxonomy were the revision to action
verbs from nouns and the switch between the fifth and sixth objective. This revi-
sion also added a second dimension to the cognitive taxonomy with levels of
knowledge in addition to the hierarchy of cognitive objectives. These levels of
knowledge included factual, conceptual, procedural, and metacognitive.
Likely based on the hierarchical framework of Bloom’s taxonomy, Miller created

a framework specifically designed for medical education clinical competency ob-
78
jectives often referred to as Miller’s pyramid.7 This hierarchy begins with basic
objectives categorized as ‘knows’ (knowledge) and ‘knows how’ (how to apply
knowledge) objectives and then moves into application objectives of ‘shows’
(shows how to apply knowledge) and ‘does’ (applies knowledge in practice). In
practice-based fields, lower level knowledge objectives are often required before
higher-level application based objectives can be attained. The pyramid keeps a
focus on the overall goal of medical education, which is to create competent prac-
ticing physicians who must function in the “does” domain during patient care.
In addition to the creation of learning objectives, the Bloom’s taxonomy assists in

developing instructional methods, assessments, and program evaluations. Often
educators create higher level educational goals for a course, but only assess
lower level goals. The most common scenario is the use of a multiple choice test
for student assessment. This tool functions well to assess remembering, but fails
to assess the higher level goals of evaluating, and synthesizing. The level of as-
sessment should match the level of the stated goals for an educational activity.
In addition to matching assessment methods to learning objectives, the Bloom’s

taxonomy and Miller’s pyramid can help determine the instructional methods to
be used. For instance, if one is trying to teach psychomotor skills or higher-level
Miller ‘does’ skills, one should match the instructional methods accordingly. In
this case, lectures or other passive learning sessions may not be appropriate;
rather, instructing and assessing with simulation or standardized patients might
be more appropriate.
Many of the limitations or criticism of Bloom’s Taxonomy stem from the original
work. Such criticisms included the lack of a separate knowledge hierarchy
within the cognitive objectives, the original omission of understanding as a level
79
of the cognitive hierarchy, and the order of the hierarchy. These issues have been
largely addressed by the revisions in 2001.
The other main criticisms revolve around the universal adoptions of objective
-based learning and assessment, without solid evidence behind the taxonomy.
Some feel that the use of objective-based learning is an oversimplification of edu-
cation programing. It prevents viewing the education program as whole entity;
instead it separates it into component pieces. Furthermore, Bloom describes his
objectives as ‘intended’ behaviors of students, which may be overly categorical. In
general, the taxonomy serves as a means for creation, evaluation, and revision of
teaching objectives in a common and defined language.
Often higher-level objectives or assessments are desired, but not feasible. In addi-
tion, many critique Bloom’s original work, stating that achieving lower level
learning objectives is not always necessary before achieving higher level learning
objectives. This may be true when advances in technology reduce the need for
certain knowledge prior to practice.
Finally, many criticize the lack of evidence behind the taxonomy. The initial tax-
onomy and subsequent revisions are mostly theoretical and based on expert opin-
ion from those within the Bloom school of thought. Though most agree that there
are separate realms of motor/practice-based learning and knowledge based learn-
ing, there is no solid evidence to support the separate domains of the taxonomy
or specific organization of the hierarchy in education and outcomes.
80
1. Adams NE. Bloom’s taxonomy of cognitive learning objectives. J Med Libr

Assoc. 2015;103(3): 152–153.  
This article provides short and precise examples of each level considered in the
classification. The author concludes that this tool is helpful in two important ways: 1)
helps the instructor to think of learning objectives in behavioral terms and 2) forces
us to include learning objectives that require higher levels of cognitive skills. If one
combines both benefits, it will lead to a deeper learning and transfer of knowledge and
skills to a greater variety of tasks and contexts.
2. Phillips AW, Smith SG, Straus, C. Driving Deeper Learning by

Assessment: An Adaptation of the Revised Bloom’s Taxonomy for Medical
Imaging in Gross Anatomy. Acad Radiol. 2013;20:784–789. 
Using Bloom’s taxonomy, a group of radiologists and anatomists prepared different
types of questions that assessed different hierarchical categories. As they
hypothesized, they found that there was an inverse relationship between a student’s
score and the level of the cognitive domain tested by the question, supporting the
existence of discrete hierarchical levels of cognition.
3. Larkin BG, Burton KJ. Evaluating a Case Study Using Bloom’s Taxonomy
of Education. AORN J; 2008;88:390-402. 
Authors took a near miss case in a postoperative unit in a large trauma center and,
using Bloom's taxonomy. They designed a workshop with clear and explicit
educational objectives. They observed that the objectives helped the clinical team
identify gaps in communication.
4. Zeng AY, Lawhorn JK, Lumley T, Freeman S. Application of Bloom’s

Taxonomy Debunks the MCAT Myth. Science. 2008;319(5862):414-5. 
The initial hypothesis was that the Medical College Admission Test (MCAT) used a
larger quantity of higher order cognitive questions than other tests. Comparing six
different tests, including MCAT, they found no difference between the number of
questions assessing lower levels of knowledge and those evaluating higher levels,
including none assessing synthesis and evaluation levels.
81
Dr. French spoke to a colleague regarding his dilemma and was introduced to Bloom’s tax-
onomy as a method for classifying goals and skills. Dr. French performed a needs assess-
ment and found that the interns were lacking higher level cognitive skills, rather than psy-
chomotor or emotional skills.
Dr. French began revising the airway course curriculum. He understood that Richard’s
knowledge deficit lied in the higher end cognitive domain (applying, analyzing, evaluat-
ing, and synthesizing), or in the ‘shows’ or ‘does’ objectives in the Miller pyramid of medi-
cal education. Therefore, he needed to create objectives and use teaching methods and as-
sessment tools aimed at this level of learning.
He first created the objective: the intern will correctly identify five clinical scenarios in
which patients require endotracheal intubation. In order to teach this objective, he built
on the current curriculum. He decided to keep the lecture format for the purpose of teach-
ing the basic ‘remembering’ type knowledge objectives. He then created a series of video
clinical vignettes with actors; learners were forced to decide which patients required intu-
bation. The scenarios included vital signs, blood gas results, and any physical exam
findings/radiographic information that were needed.
Dr. French gave the lecture; led the residents in a small group discussion about the indica-
tions for intubation, and then challenged them with the video clinical vignettes.
He knew that he also had to assess the residents’ new knowledge and skills. He wanted to
ensure that the students had moved beyond the knowledge objectives and were able to ap-
ply their knowledge. The current method focused only on techniques and difficult airway
scenarios. Dr. French added a few additional scenarios and altered some of the current sce-
narios to focus on the decision of whether to intubate; he even included some cases in
which the patient should not be intubated.
Finally, Dr. French created a specific assessment checklist tool for each scenario, focusing
on the levels of cognitive objectives including:
82
1. Learner voices the specific indication for intubation (understanding/remembering).
2. Learner collects the proper information needed to make the decision to intubate (apply-
ing, analyzing).
3. Learner correctly interprets the information gathered (analyzing, evaluating).
4. Learner makes the correct decision to intubate for the correct reasons (synthesizing). 
After application of his new simulation-based sessions focusing on indications for intuba-
tion, Dr. French was happy to find that in Richard was able to make appropriate decisions
about whether to intubate a patient in the subsequent months and years.
83
REFERENCES
1. Bloom BS, Committee of College and University Examiners. Taxonomy of educational objectives. New
York: Longmans, Green; 1964.
2. Anderson LW, Krathwohl DR, Airasian P, Cruikshank K, Mayer R, Pintrich P, Raths J, Wittrock M. A
taxonomy for learning, teaching and assessing: A revision of Bloom’s taxonomy. New York. Longman
Publishing; 2001.
3. Krathwohl, D., Bloom, B., and Masia, B. (1964). Taxonomy of Educational Objectives: The Classifica-
tion of Educational Goals - Handbook II: Affective Domain. New York, NY: Longman; 1964.
4. Harrow A. A Taxonomy of The Psychomotor Domain: A Guide for Developing Behavior. London:
Longman; 1972.
5. Simpson EJ. Educational objectives in the psychomotor domain. Behavioral objectives in curriculum
development: Selected readings and bibliography. 1971;60(2).
6. Dave RH. Developing and writing behavioural objectives. Educational Innovators Press; In:
Armstrong,R.J. (Ed); 1975.
7. Miller GE. The assessment of clinical skills/competence/performance. Academic medicine. 1990 Sep
1;65(9):S63-7.
84
CH APT E R 9
Dual Process Reasoning

Authors: Antonia Quinn, DO; Daniel Robinson, MD; Adam Tobias, MD, MPH 
Editor: " Lalena M. Yarris, MD, MCR 
A CASE
Jason was a second-year emergency medicine resident. Faculty members frequently
remarked that he was one of the most efficient members of his class, able to handle a
higher patient volume, seeing his patients through to a timely disposition. He often saw
patients with common, straight-forward presentations, such as typical chest pain or viral
upper respiratory infections, and had the correct work-up started and the patient “teed
up” for the attending before they had even seen the patient.
However, faculty members had also noted that Jason struggled when patients presented
atypically, or when they presented with multiple complaints. In those cases he tended to
“shotgun a bunch of tests” without giving much thought about his differential diagnosis.
The residency leadership was also concerned because he scored well below his classmates
on the prior year’s in-training exam.
The residency leadership wanted to intervene to bring Jason up to the right standard, but
were struggling to identify the flaw in his reasoning abilities, particularly because he
seemed to excel so well in some areas and lag behind in others.
• Why is Jason having trouble with atypical cases?
85
OVERVIEW | DUAL PROCESS REASONING
Dual Process Reasoning is a theory which has evolved over the past century, dating
back to Sigmund Freud,1 who suggested that reasoning involved two separate
systems for information processing: one unconscious and associative, the other
rational and conscious.
The current framework for this system, described by Stanovich and West, identifies
two systems of thinking, which individuals alternate between depending on their
own pre-existing framework and characteristics.2 System 1 is automatic and
unconscious and relies heavily on contextual clues. System 2, on the other hand, is
conscious and analytical and is used independent of context.3-5
It is proposed that an individual’s cognitive abilities are dependent on the degree to

which they employ each of the two systems. This results in two types of
intelligence: interactional intelligence (System 1) and analytic intelligence (System 2).
It was proposed that individuals with higher cognitive abilities employ more System
2 thinking (i.e. they are able to rely more on their analytic abilities and less on
heuristics available in System 1).1 Some believe that each of these two systems
evolved to serve a different evolutionary purpose. System 1 evolved to serve the
process of reproduction and gene propagation, while System 2 evolved to serve “the
interests of the whole person.”
MAIN ORIGINATOR OF THE THEORY
Sigmund Freud
Although not a primary text by Freud, the following is an approachable
commentary that highlights Freud’s original dual process theory: 
Brakel LA, Shevrin H. Freud's dual process theory and the place of the a-
rational. Behavioral and Brain Sciences. 2003 Aug;26(4):527-8.
86
Keith E. Stanovich & Richard West  

(who were responsible for coining the terms System 1 and System 2)
• Stanovich KE, West RF. Individual differences in reasoning: Implications for
the rationality debate?. Behavioral and brain sciences. 2000 Oct;23(5):645-65.
Daniel Kahneman & Amos Tversky

• Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases.
InUtility, probability, and human decision making. Springer, Netherlands,
1975: 141-162.
Peter C. Wason
• Wason PC, Evans JS. Dual processes in reasoning?. Cognition. 1975 Dec
31;3(2):141-54.
Steven A. Sloman
• Sloman SA. The empirical case for two systems of reasoning. Psychological
bulletin. 1996 Jan;119(1):3
Pat Croskerry
• Croskerry P. Clinical cognition and diagnostic error: applications of a dual
process model of reasoning. Advances in health sciences education. 2009 Sep
1;14(1):27-35.
Silvia Mamade
• Mamede S, Schmidt HG, Rikers R. Diagnostic errors and reflective practice in
medicine. Journal of evaluation in clinical practice. 2007 Feb 1;13(1):138-45.
• Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and
theory of debiasing. BMJ Qual Saf. 2013 Jul 23:bmjqs-2012.
• Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to
and strategies for change. BMJ Qual Saf. 2013 Aug 30:bmjqs-2012. 
87
BACKGROUND
The distinction between intuitive and analytical thinking was first described by
the Greek philosophers. The ancients believed that the intuitive thought process
was “actually a superior state of mind.”2 However, in the early twentieth century,
French philosophers described the intuitive thought process as unconscious,
highly subject to bias, and sometimes irrational.2 The dual process theory is one
of many approaches towards decision making. However, the dual process theory
is highly regarded, and two Nobel prizes have been awarded for the scientific
work regarding human decision-making (Herbert Simon in 1978 and Daniel Kah-
neman 2002). In 2009, Pat Croskerry published a manuscript in Advances in Health
Science Education entitled: Clinical cognition and diagnostic error: applications of a
dual process model of reasoning.4 This manuscript describes the application of the
dual process model in clinical practice.
Dual process theory has informed models of clinical reasoning that are generally
accepted in the medical education literature. There is general consensus that both
System 1 reasoning (which can be thought of as pattern recognition) and System 2
reasoning (or analytic reasoning) occur in clinical decision making. However,
there are differing opinions regarding the association between reasoning type
and cognitive errors, as well as how applications of dual process learning may be
able to reduce or prevent errors.6
Croskerry posits that most medical errors are a failure of cognitive reasoning and
over-reliance on System 1 processes and cognitive biases that result. He suggests
that clinicians should focus on reducing medical errors and cognitive biases and
that physicians should make every effort to access System 2 to force analytical
thinking in a hectic clinical environment.4 However, System 2 is a slower and of-
ten inefficient system. How does one increase the efficiency of System 2 and de-
crease the error rate of System 1? Croskerry believes that clinicians need to im-
prove their ability to recognize patterns and be keenly aware when a scenario
does not fit an established pattern.4
88
Daniel Kahneman, in ‘Thinking Fast and Slow’, argues that:
Memory also holds the vast repertory of skills we have acquired in a lifetime of prac-
tice, which automatically produce adequate solutions to challenges as they arise,
from walking around a large stone on the path to averting the incipient outburst of
a customer. The acquisition of skills requires a regular environment, an adequate
opportunity to practice, and rapid and unequivocal feedback about the correctness
of thoughts and actions. When these conditions are fulfilled, skill eventually devel-
ops, and the intuitive judgments and choices that quickly come to mind will
mostly be accurate.4
In accordance with dual process theory, many of today’s undergraduate and

graduate medical education programs focus on early patient encounters, analysis
of clinical cases and simulation.
In a recent narrative review,6 the literature describing the relationship between

System 1 and System 2 processing (called Type 1 and Type 2 in this article) and rea-
soning errors is examined, and two theories regarding errors are explored:
1. All errors originate from heuristics employed in System 1 reasoning and not
corrected by the application of System 2 reasoning; and
2. That errors arise from both processes, and errors may be reduced by increas-
ing knowledge.6
The authors conclude the errors can arise from both types of processing, and they
do not find evidence to support that errors can be reduced by training physicians
to recognize biases or warning them to “slow down”, or try to force System 2 rea-
soning. However, there is some evidence that reorganizing knowledge and ad-
dressing knowledge gaps may decrease diagnostic error.
Outside of the clinical setting, dual process theory can be applied to learner per-
formance on simulated cases in written or computer exams, oral presentations,
and low- or high- fidelity scenarios.
89
In the clinical setting, educators should be aware that learners likely use both
types of processing, and exploring diagnostic reasoning strategies may give in-
sight to knowledge gaps. Addressing these gaps may reduce the possibility for
error. Establishing evidence-based clinical pathways may help reduce errors by
encouraging adherence to guidelines, and decreasing the risk of error due to
knowledge gaps.5
Kahneman stated, “The way to block errors that originate in System 1 is simple in prin-
ciple: recognize the signs that you are in a cognitive minefield, slow down, and ask rein-
forcement from System 2.”5 Although the simplicity of this principle is appealing,
recognizing that one is in a minefield, and slowing down in the chaotic clinical en-
vironment of the ED is likely to prove challenging. Further, it is not clear that
forced analytic reasoning reduces errors or improves performance.6 There may be
other benefits to teaching learners how to incorporate checks and balances into
their clinical routine, particularly in the form of checklists and evidence-based
guidelines. As our understanding of how dual process reasoning theory can be
applied to teaching and assessing clinical reasoning, improving performance,
and error reduction, further educational applications may emerge.
Dual process reasoning can be thought of as a general framework by which one

may approach various problems of cognition, either in medical education or in
other areas that require problem-solving and the complexities of human thought.
While the theory can be incorporated the way that we analyze physician perform-
ance, how medical trainees integrate new information, and why errors occur, it
should not be considered the only available lens. While much insight can be
gained by considering the dual process system, other theories may provide addi-
tional clarity in certain scenarios. Educational theories allow us to approach is-
sues from a variety of angles, and should be thought of as synergistic rather than
exclusive of each other. The true depths of human cognition will never be amena-
ble to incorporation into a single, simplified theory.
90
The paper by Evans and Stanovich in 2013 summarizes multiple limitations of
dual process reasoning into themes.8 They review existing (and at times conflict-
ing) definitions of dual process reasoning and describe how researchers’ attempts
to create clusters of attributes associated with each system have not provided con-
sensus consistent across all accompanying theories. Although single theory expla-
nations of dual process reasoning have been proposed3,7, there may be limita-
tions in dichotomizing a process that may represent more of a continuum. Fur-
ther, the applications of dual process reasoning are controversial, particularly
when considering the complex relationship of processing strategy to cognitive
errors.6-13
1. Stanovich KE, Toplak ME, West RF. The development of rational thought: A
taxonomy of heuristics and biases. Advances in child development and
behavior. 2008;36:251-285. 
This comprehensive chapter on rational thought from a psychology perspective reviews
theory regarding rational thought, or “adopting appropriate goals, taking the appropriate
action given one’s goals and beliefs, and holding beliefs that are commensurate with
available evidence.” Rational thought is defined, dual-process theory is described, and the
authors provide a taxonomy of rational thinking errors, classify heuristics and biases, and
provide exemplary studies of categories of errors.
2. Croskerry P. Clinical cognition and diagnostic error: applications of a dual

process model of reasoning. Advances in Health Sciences Education. 2009;14(1):
27-35. 
In this paper, Croskerry describes dual process theory as it applies to medical decision
making, presents a schema for how approaches to decision making fit within the intuitive-
analytical continuum. He compares and contrasts System 1 and System 2 thinking, and
proposes applications of the model, including a template for teaching decision theory, a
platform for future research, and a proposal for how errors may occur in diagnostic
processes.
91
(CONT’D)
3. Kahneman D. Thinking, fast and slow. Macmillan; 2011.  

This book, written for the general public, written by psychologist and economist
Kahneman, describes dual process theory in terms of “fast and slow thinking,” referring to
subconscious versus conscious thought. The author describes his understanding of
judgement and decision making, using anecdotes and examples the reader can relate to.
The book walks the reader through a description of System 1 and System 2 thinking,
describes the literature on heuristics, explores our tendency to have excessive confidence in
what we know, applies economic principles to decision making, and differentiates between
the “experiencing self and the remembering self.” A final chapter explores the implications
of the distinctions drawn in the book.
4. Ilgen JS, Humbert AJ, Kuhn G, Hansen ML, Norman GR, Eva KW, Charlin B,
Sherbino J. Assessing diagnostic reasoning: a consensus statement summarizing
theory, practice, and future needs. Academic Emergency Medicine. 2012 Dec
1;19(12):1454-61.  
This proceedings paper from the 2012 Academic Emergency Medicine Consensus
Conference on Education Research outlines existing theories of diagnostic reasoning as
they apply to Emergency Medicine, and describes strategies for assessing clinical
reasoning. The authors then propose gaps in the reasoning literature and consensus-based
priorities for future research on clinical reasoning.
5. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The
causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and
dual process thinking. Academic Medicine. 2017 Jan 1;92(1):23-30.  
This literature-based opinion piece by experienced clinical reasoning researchers reviews
dual-process models, describes their application to cognitive decision making, and describes
the literature that explores the relationship of reasoning processes to cognitive errors.
Readers will find the overview helpful, the arguments relevant, and the references of
interest.
92
The residency leadership determined that Jason was really good with System 1 decision-
making in cases that were familiar to him, but lacked the experience necessary for System
1 decision-making to be consistently effective. He also struggled with applying System 2
decision-making when cases didn’t fit a pattern familiar to him. The faculty met with Ja-
son to discuss his cognitive decision-making with him and developed strategies to get him
to slow down and be more analytical when a clinical presentation did not immediately fit
an obvious pattern. However, given the evidence that slowing down alone may not im-
prove diagnostic reasoning, he also embarked on a structure plan to remediate knowledge
gaps.10-12
Since cognitive ease may improve analytical thinking, the residency leadership believed
that Jason may have benefited from a low stress and supportive environment. Simulation
was ideal for this. Jason was placed on a remediation program that involved dedicated
simulation time. Jason met weekly with the simulation division, whose faculty members
exposed him to small tweaks of a clinical case to assess if he noticed the subtle differences
in each variation of the case. Atypical cases were incorporated to bolster Jason’s experi-
ence base.
Jason had his shifts paired with a well-seasoned, efficient senior resident where he was not
relied upon to optimize patient throughput and was able to really digest each case. He
also met with a faculty member to discuss a variety of clinical decision rules and illness
scripts. Finally, recognizing that knowledge gaps may be responsible for cognitive errors,
regardless of the processing system applied, the residency leadership worked with Jason to
develop a plan for identifying and remediating knowledge gaps, and ongoing self-directed
learning to improve his foundational understanding of what differentiates, and how to ap-
proach, common EM presentations.
93
REFERENCES
1. Brakel LA, Shevrin H. Freud's dual process theory and the place of the a-rational. Behavioral and
Brain Sciences. 2003 Aug;26(4):527-8.
2. Stanovich KE, Toplak ME, West RF. The development of rational thought: A taxonomy of heuristics
and biases. Advances in child development and behavior. 2008;36:251.
3. Osman M. An evaluation of dual-process theories of reasoning. Psychonomic bulletin & review. 2004
Dec 1;11(6):988-1010.
4. Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reason-
ing. Advances in health sciences education. 2009 Sep 1;14(1):27-35.
5. Kahneman D. Thinking, fast and slow. Macmillan; 2011 Oct 25.
6. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clini-
cal reasoning: cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine.
2017 Jan 1;92(1):23-30.
7. Kruglanski AW, Gigerenzer G. Intuitive and deliberate judgments are based on common principles.
Psychological review. 2011 Jan;118(1):97.
8. Evans JS, Stanovich KE. Dual-process theories of higher cognition: Advancing the debate. Perspec-
tives on psychological science. 2013 May;8(3):223-41.
9. Ilgen JS, Humbert AJ, Kuhn G, Hansen ML, Norman GR, Eva KW, Charlin B, Sherbino J. Assessing di-
agnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Academic
Emergency Medicine. 2012 Dec 1;19(12):1454-61.
10.Norman G, Sherbino J, Dore K, Wood T, Young M, Gaissmaier W, Kreuger S, Monteiro S. The etiology
of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Academic Medicine.
2014 Feb 1;89(2):277-84.
11.Sherbino J, Kulasegaram K, Howey E, Norman G. Ineffectiveness of cognitive forcing strategies to re-

duce biases in diagnostic reasoning: a controlled trial. Canadian Journal of Emergency Medicine. 2014
Jan;16(1):34-40.
12. Monteiro SD, Sherbino J, Patel A, Mazzetti I, Norman GR, Howey E. Reflecting on diagnostic errors:
taking a second look is not enough. Journal of general internal medicine. 2015 Sep 1;30(9):1270-4.
13.Brush JE, Sherbino J, Norman GR. How expert clinicians intuitively recognize a medical diagnosis.
The American Journal of Medicine. 2017 Feb 24. Online first, available at:
http://www.amjmed.com/article/S0002-9343(17)30165-1/fulltext
94
CH APT E R 1 0
Gaming & Gamification

Authors: Will Sanderson, MD; Samantha L. Wood, MD 
Editor: " Lalena M Yarris, MD, MCR; Dimitri Papanagnou, MD, MPH, EdD(c);  
" " Michael Gottlieb, MD; Teresa Chan, MD, MHPE
A CASE
Thad was feeling really burnt out. It was December, and he was halfway through his
four-year residency. The beginning of intern year felt like forever ago. He has just come
off of a run of particularly brutal off-service rotations (during which he guiltily ignored
the stack of textbooks and articles on his desk), and he was happy to now be back on his
home service for a month.
He hadn’t seen his fellow residents since September, and Thursday during conference was
the first opportunity he would have to catch up. Too bad he’d have to sit through 5 hours
of mind-numbing lectures in exchange for the chance to socialize with his classmates.
It was Wednesday evening and Charlotte, Thad’s roommate, was all fired up.
“This is epic.”
Charlotte had picked up the latest installment in the Call of Duty series for their shared
Xbox One on the way home. She was a pro, and had already spent 3 hours tearing into
the game’s Campaign mode. “You need to check this out, Thad. It’s ri-donk-ulous.”
“Can’t. Got conference in the morning. I gotta prep.”
“Oh, c’mon. How can that compare to this? You haven’t been there in months anyway –
what could you be missing? Just read one of those big brain textbooks you have, or listen
to that goofy guy on that nerdy podcast you listen to.”
95
Thad thought about what Charlotte had to say. Her point was well taken. After all, he
deserved it, right? He could immerse himself in the world of modern warfare, kick
Charlotte's behind, and still not lose much if he just caught up later.
“You’re smarter than you look, Charlie. … I’m in.”
• What elements from Thad’s gaming interests might be applied to his academic
learning?
96
OVERVIEW | GAMING AND GAMIFICATION
The most basic approach in applying games to medical education is
gamification, which is the application of game-like properties to non-game
situations.1 The game-like properties may include rules of play, point
scoring, competition with others, chance, and reward for “winning”.
Serious Games
The term “serious game” refers to an interactive game, often played on a
computing device, that has a challenging goal, is fun to play and engaging,
incorporates some scoring mechanism, and supplies the user with skills,
knowledge, or attitudes useful in reality.1 A serious game has the following
characteristics:
• A defined outcome that learners must achieve
• Rules that limit the learner’s path to the goal
• Feedback to the learner
• Voluntary participation
• Achievement of “flow” in skill and difficulty level
Other Useful Definitions

Gamification is the use of game design in a non-game context. Gamification
has been applied to learning in order to increase motivation and
engagement.
The following definitions may be helpful:

• Game: A form of play or sport, especially a competitive one, played
according to rules and decided by skill, strength, or luck.
• Gaming: The playing of games.
• Gamification: The application of typical elements of game playing (i.e.,
point scoring, competition with others, rules of play) to other areas of
activity.
• Serious Game: An interactive application that has a challenging goal, is
fun to play and engaging, incorporates some scoring mechanism, and
supplies the user with skills, knowledge, or attitudes useful in reality
97
• Thomas Malone
• Nick Pelling
• Katie Salen
• Bryan Bergeron
BACKGROUND
Although educators have undoubtedly been using game playing elements to en-
hance learners’ experience and retention for centuries, one of the first broadly dis-
tributed examples of gamification in education was the creation of “Where in the
world is Carmen Sandiego?” in the mid 1980’s.2
Gamification of education can intersect with other educational theories. For ex-
ample, combining behaviorism with gamification tells us that the receipt of a “re-
ward” (points) is likely to encourage a desired behavior (answering a question
correctly).3 A social constructivist application of gamification will place partici-
pants in teams and present them with a problem that requires collaboration and
construction of new knowledge in competition against other groups.3
Serious games differ from gamification in their reliance on the learner’s intrinsic
motivation to continue the game. A serious game should continually stretch the
learner by operating at the outer level of his or her competence and presenting
concrete challenges that become harder as skills are mastered. This “just out of
reach” approach to motivation applies the Yerkes-Dodson Law4 to achieve the
ideal level of “stress” to encourage maximal learning conditions. The serious
game endeavors to situate the user at a state where he or she is experiencing
“flow” (the psychological state of enjoyment while learning is taking place,
which was theorized by Csikszentmihalyi)5 and simultaneously challenged to
master material slightly out of reach aligns with Ericsson's concept of deliberate
practice.6
98
One key limitation of serious games is the need for user initiative, although the
underlying principle is that once the user starts playing, he or she will find the ex-
perience enjoyable and be motivated to continue. Additionally, the reliance of se-
rious games on computers may exclude participants who cannot access or are not
comfortable with the technology.
POSSIBLE POINTS OF CONFUSION
Of note, when educators look into gamification, they may come across game the-
ory, which is decidedly different. Game theory is a branch of mathematics dedi-
cated to the study of mathematical models of conflict and cooperation between
intelligent, rational decision makers. It was originally applied to “zero sum
games” where the gains of one “player” meant losses for other players. After the
establishment of the pre-existing conditions, game theory is applied to evaluate
the likely outcome of the “game”, in particular how different “strategies” will re-
sult is different “payoff” for the players. The classic example of game theory is
the prisoner’s dilemma.7 In this “game”, two prisoners are arrested for the same
crime. They are placed in separate cells and are told that another person has also
been arrested for the crime. The prisoner must decide whether to remain silent or
testify against the other prisoner.
The possible outcomes include:
• If both prisoners remain silent (“cooperate”), they each serve 1 year in prison.
• If both prisoners testify against each other (“defect”), they both serve 3 years in
prison.
• If one prisoner “cooperates” and the other “defects”, the one who defects will
go free while the other will serve 10 years in prison.
Games should also be distinct from toys, puzzles, and stories. A game is not a
toy; toys are free-form and open-ended. In contrast to toys, games have structure,
rules, and goals. A game is not a puzzle; puzzles are static and have only one so-
lution. In contrast to puzzles, games are dynamic and require strategies to arrive
99
to solutions. Lastly, a game is not a story; stories are linear and passive. In con-
trast to stories, games are non-linear and interactive.
Many would consider that gamification itself is already the modern take on be-
haviourist theories, which originated with B.F. Skinner.8 Skinner’s work incorpo-
rated a number of facets that teachers will note are seen in gamification or other
gaming platforms (e.g. positive reinforcements, small step-by-step tasks, feed-
back that is provided to students immediately, progressively difficult challenges).
That said, gamification should not be exclusively thought of as just a reinvention
since it also integrates a fairly important social component and allows for multi-
ple outcomes and paths to success, which is unlike Skinner’s original work.3
OTHER EXAMPLES OF WHERE THIS THEORY MIGHT APPLY
Applications of gamification in the clinical and classroom setting can take many
forms. Some examples include:
Simulation
• Simulations are activities that center on simulated use of the skill(s) to be devel-
oped. Simulations typically require a model of the situations in which the skills
would be used and the variables that affect the decisions the ‘player’ makes.
• Classically, simulation has not been perceived from the lens of “gaming” or
gamification, as it seeks to mimic reality. That said, more recent applications
suggest simulation can be reconceptualized to emphasize a gameplay-type ap-
proach. Sunga and colleagues suggest that using simulation in a gameplay
manner may be useful for learning.9
Virtual Environments10
100
• This may also be valuable for resuscitation training. Online scenarios for recerti-
fication in online teaching platforms also resemble video games and other
learning tools.11
• Creation of a trauma patient simulator with points awarded for correct actions
taken and increasing level of difficulty as the learner succeeds.12
Social and Cooperative Play13
• Assignment of points for correct answers in resident conference and giving a

prize to the winner.
• Organization of a competitive wearable fitness device community to encour-

age resident wellness.
• Challenging a learner to a task bound by “rules of play” in the clinical setting

(i.e. “I want you to go do a lung exam on Mr. Jones and then come tell me what
you think we’ll see on the chest x-ray” or “Pull up the head CT on Mrs. Smith
and tell me how the findings relate to her symptoms”).
A Simple Model of Game Development to Support Learning
Should an educator and/or instructional designer want to apply gamification or

gaming to learning and learning outcomes, the following model can assist him/
her with considering necessary elements to ensure the development of a sound,
educational game.14
• Player (i.e., Learner) Decision and Actions: The educator should first consider
the skills the player needs to learn, and the specific actions that the learner
would need to take to build on these skills. This process will also assist the edu-
cator in identifying any decisions the learner will need to make regarding these
skills, as well as the situations, resources, and any other factors that would in-
fluence these decisions. Each of these factors should be considered as variables
that will contribute the success of a successful educational intervention that lev-
erages gamification or gaming strategies.14
101
• Feedback: The educator should build-in a process that evaluates the learner
during the game, which should distinguish between correct and incorrect (or
good versus bad) decisions. It should also be predetermined now these objec-
tive evaluations will affect the course of the game (i.e., does it change the score,
the resources available, or future options). The educator should also decide the
time with which feedback is delivered to the learner (i.e., is it delayed or is it
immediate).14
• Goals: The goals of the game should be clearly delineated. Ideally, these goals
should be congruent with the educator’s learning objectives. Additionally,
does the successful achievement of these goals trigger the end of the game, or
does the learner continue to be immersed in the game?14
• Mechanics/Resources: Game mechanics define how learners’ decision in the

game interact with game objects (i.e., characters, issues). This is where the edu-
cator designs the game to abstract real-world concepts or learning issues into
game objects. Additionally, the educator should consider any resources the
learner will need to use throughout the game (i.e., time, money, lives, turns).14
• Challenge Curve: Learning during the game will come from encountering chal-
lenges and devising methods to overcome them. Potential challenges may in-
clude, but are not limited to, the following: active opposition (i.e., the obstruc-
tive consultant); parallel competition (i.e., competing with fellow resident); lim-
ited resources (i.e., limited diagnostic testing); and limited time. Fine-tuning
the progression of challenge is one of the most important aspects of ensuring a
successful learning game. The length of the game should also be predeter-
mined, as the duration of the game will dictate how much time is realistically
available to allow for an increasing challenge curve.14
• Playtest: It is advised that the educator and/or instructional designer test (or
play) the game several times before it is introduced to learners. Both experi-
ences and junior learners can also be invited to test the game. During this itera-
tive process, feedback from participants should be incorporated into fine-
tuning the game in order to ensure it meets the overarching goals and learning
objectives.14
102
Limitations of gamification include the risk that learners will find the experience
undesirable and “opt out” (for example, if learners find it distressing to answer a
question wrong in conference or feel ashamed if their point total is low, they may
choose not to participate; additionally learners may opt out if the “reward” is not
sufficiently desirable). Gamification is also most appropriately applied to fairly
straightforward decision making rather than complex thought processing.
103
1. Akl EA, Pretorius RW, Sackett K, et al. The effect of educational games on
medical students’ learning outcomes: A systematic review: BEME Guide
No 14. Med Teach. 2010;32(1):16-27.  
This article is a systematic review evaluating the effect of educational games on
medical students’ satisfaction, knowledge, skills, attitudes, and behaviors. Given the
associated costs (e.g. time, resources, preparation) associated with educational games,
the authors sought to determine whether a significant benefit resulted from its
implementation. The resulting studies highlight the limited existing high-quality
literature. The authors also provide a bibliography of other relevant studies.
2. McCoy L, Lewis JH, Dalton D. Gamification and Multimedia for Medical

Education: a Landscape Review. J Am Osteopath Assoc. 2016;116(1):22-34.  
This review article is a descriptive study of existing gaming resources available for
use in medical education. The authors provide evidence supporting the value of
gamification, followed by a list of 45 available resources with a table summarizing the
basic design, product highlights, and how to access them. This can be a valuable early
resource when seeking to utilize gamification for medical education at one’s
institution.
3. Bíró GI. Didactics 2.0: A pedagogical analysis of gamification theory from a

comparative perspective with a special view to the components of learning.
Procedia-Social and Behavioral Sciences. 2014 Aug 25;141:148-51.  
This article discussed the unique value of gamification for the Generation Z learner,
emphasizing the utilization of online resources, socialization, increased interactivity,
and positive reinforcement. Next, the author compares gamification with several
existing learning theories, highlighting several similarities and differences that make
gamification unique. Finally, the article addresses the importance of further study
and possible future directions.
104
BEEP BEEP BEEP BEEP
“Jeez…enough already,” Thad muttered to himself as he fumbled to turn off his alarm.
He looked at the time. 1:00 pm. “Crap. I missed conference again.”
He and Charlotte had spent the rest of last night playing online multiplayer and finally
crashed at 5:00 am. He felt a bit guilty for missing out on conference... but it was always
so boring, so he didn’t feel a lot of regret. He knew he’d better off just sleeping, and then
reading the material on his own later.
That said, he knew that was no excuse. He couldn’t justify to his peers and the program
administrator that he would not be attending conference because it was boring; after all,
he was a professional now - an adult - and if he didn’t learn the stuff he needs to learn it
will be his patients that suffer. There had to be a better way…
Later that afternoon, Thad texted his Assistant Program Director to see if she could meet
up for a coffee.
“I’ve got some ideas I want to run by you,” he wrote. She quickly texted back suggesting
that they meet at a local coffee shop. Dr. Cozart has always been pretty cool and approach-
able, and she was happy to meet with him.
As soon as she arrived, Thad began with an apology:“I’m sure you noticed this…I wasn’t
at conference today. And I am sorry for that. I’m not here to make excuses, and really I
should’ve been there no matter what. But I’m going to be straight with you: I spent all
night playing Call of Duty and it was awesome. It gives me a sense of play and competi-
tion that I just haven’t seemed to find yet in residency. So here’s my question for you: is
there a way we can incorporate gaming into our resident education?”
Dr. Cozart paused. “Well, I can’t say I’m shocked that you weren’t there, but I’m really
pleased you took the initiative here. I’ve been looking for a resident champion for confer-
ence to increase interest. Because let’s be honest – there’s been no interest. Our seniors are
barely making the attendance cutoffs for graduation, and when residents are present
they’re completely absent with respect to their attention. In fact, I could have sworn I saw
105
one of your colleagues creating face-swapping videos with a glittering pink bullmastiff on
Snapchat throughout the entire thyroid storm lecture.”
“Yeah. They do that.”
“Why? Wait, don’t answer that.”
“Well I don’t know a lot about how we’d do this or any of that educational design stuff
that you do, but I’d be happy to help out in any way I can. I want to learn and I want
things to be better for all of us.”
“Great! Well you know we do something similar during our sim days, but I think that
there are opportunities to do more. Have you heard of this thing called the ‘Virtual ED’?
“No.”
“Well it’s based on this concept of creating virtual online worlds, kind of like – what was
the name of that game you…”
“Call of Duty.”
“Call of Duty… OK I guess kind of sort of like that. Well what you can do is have people
log in to this virtual ED and act out scenarios by moving their people around the room
just like they would in sim. They can be elsewhere and log into a browser. They have a mi-
crophone on their end and everyone else in the virtual room can hear everything.”
“Wait! We could split up our residency into 4 groups and have like a competition or team
based thing where they all compete to try to win the VEC!!!”
“The VEC????”
“The Virtual ED Championship. Work with me here.”
“I’m trying.” Dr. Cozart was smiling. “I think you’re onto something. You’re going to
need to flesh this out, but I think you’re onto something. You’ll need to find a way to tie it
to our core content, as you know we’ve been getting away from that lately…”
“Awesome! The residents are going to love this. Trust me.”
“I’ll grant you the former. The latter?”
“Funny. I’ll get a proposal to you by next week.”
106
REFERENCES
1. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT et al. Technology-enhanced simula-
tion for health professions education: a systematic review and meta-analysis. JAMA 2011; 306: 978–
988.
2. Hogle, J.G., 1996. Considering games as cognitive tools: In search of effective edutainment. Accessed
Jan 27, 2017: Available at: https://eric.ed.gov/?id=ED425737.
3. Bíró GI. Didactics 2.0: A pedagogical analysis of gamification theory from a comparative perspective
with a special view to the components of learning. Procedia-Social and Behavioral Sciences. 2014 Aug
25;141:148-51.
4. Cohen RA. Yerkes–Dodson Law. In: Encyclopedia of clinical neuropsychology 2011 (pp. 2737-2738).
Springer New York.
5. Nakamura J, Csikszentmihalyi M. The concept of flow. In: Flow and the foundations of positive psy-
chology 2014 (pp. 239-263). Springer Netherlands.
6. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert
performance. Psychological review. 1993 Jul;100(3):363.
7. Rapoport A, Chammah AM. Prisoner's dilemma: A study in conflict and cooperation. University of
Michigan press; 1965.
8. Skinner BF. The Technology of Teaching, Appleton-Century-Crofts, 1968.
9. Sunga K, Sandefur B, Asirvatham U, Cabrera D. LIVE. DIE. REPEAT: a novel instructional method in-
corporating recursive objective-based gameplay in an emergency medicine simulation curriculum.
BMJ Simulation and Technology Enhanced Learning. 2016 Nov 1;2(4):124-6.
10.McCoy L, Lewis JH, Dalton D. Gamification and Multimedia for Medical Education: a Landscape Re-
view. J Am Osteopath Assoc. 2016;116(1):22-34.
11.Delasobera BE, Goodwin TL, Strehlow M, Gilbert G, D'Souza P, Alok A, Raje P, Mahadevan SV. Evalu-
ating the efficacy of simulators and multimedia for refreshing ACLS skills in India. Resuscitation. 2010
Feb 28;81(2):217-23.
12.Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and
evaluation of an online virtual emergency department for training trauma teams. Simulation in
Healthcare. 2008 Oct 1;3(3):146-53.
13.Akl EA, Pretorius RW, Sackett K, Erdley WS, Bhoopathi PS, Alfarah Z, Schünemann HJ. The effect of
educational games on medical students’ learning outcomes: a systematic review: BEME Guide No 14.
Medical teacher. 2010 Jan 1;32(1):16-27.
14.Johannigman, J (January 2017). “Think Like A Game Designer: Techniques for Creating Learning
Games.” The Lilly Conference: Evidence-Based Teaching and Learning; Austin, Texas.
107
EDUCATION THEORY 
MADE PRACTICAL 
VOLUME 1
Academic Life in Emergency Medicine 

Faculty Incubator 
 
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EDUCATION THEORY

MADE PRACTICAL VOLUME 1

Chan | Gottlieb | Sherbino | Boysen-Osborn | Papanagnou | Yarris

Education Theory Made Practical: Volume 1

First edition, August 2017.

Teresa M. Chan, MD, MHPE

Thank you so much to the online communities (#MedEd and #FOAMed)

! ! ! ! - Teresa, Mike, Megan, Jon, Dimitri, Lainie

Chapter 2! Naturalistic Decision Making

Chapter 3! Communities of Practice

Chapter 4! Emotional Intelligence

Chapter 5! Social Constructivism

Chapter 6! Reflective Practice

Chapter 7! Self-Directed Learning

Chapter 8! Bloom’s Taxonomy

Chapter 9! Dual-Process Reasoning

Chapter 10! Gaming and Gamification

Chapter 2! Naturalistic Decision Making

Chapter 3! Communities of Practice

Chapter 4! Emotional Intelligence

Chapter 5! Social Constructivism

Chapter 6! Reflective Practice

Chapter 7! Self-Directed Learning

Chapter 8! Bloom’s Taxonomy

Chapter 9! Dual Process Reasoning

Knowledge of educational theory is foundational to being an effective educator. It

Topics include the theories of modal model of memory, naturalistic decision-making,

Felix Ankel, MD

Modal Model of Memory

Question for the Reader

1. Sensory register: Information initially enters via the five senses

The following figure summarizes this model.

OTHER IMPORTANT RELATED AUTHORS

The central executive system is in charge of strategy selection and integration

OTHER EXAMPLES OF WHERE THIS THEORY COULD APPLY

LIMITATIONS OF THIS THEORY

RETURNING TO THE CASE...

2. Baddeley A. Working Memory. Comptes rendus de l’Academie des sciences.

9. Ericsson K, Kintsch W. Long-term working memory. Psychological Review.1995; 102(2): 211-245.

Naturalistic Decision Making

Question for the Reader

OTHER IMPORTANT RELATED AUTHORS

Kenneth Hammond - Cognitive Continuum Theory

Jens Rasmussen - Cognitive Control

Given the number of high-pressure, high-stakes decisions made in medicine,

Macrocognition is a comprehensive framework that evaluates several compo-

OTHER EXAMPLES OF WHERE THIS THEORY COULD APPLY

In fields combining high-stakes scenarios with short clinical decision-making

LIMITATIONS OF THIS THEORY

RETURNING TO THE CASE...

1. Klein G. Naturalistic Decision Making. Human Factors 2008;50(3):456-460.

2. Lipshitz R, Klein G, Orasanu J, Salas E. Focus Article: Taking Stock of

3. Kahneman D, Klein G. Conditions for Intuitive Expertise: A Failure to

2. Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol.

5. Brighton H, Gigerenzer G. Homo Heuristicus: Less-is-More Effects in Adaptive Cognition. Malays J

11.Patel VL, Kaufman DR, Arocha, JF. Emerging paradigms of cognition in medical

Questions for the Reader

• How should Steve approach this dilemma?

• Are there resources or programs available to assist Steve?

OTHER IMPORTANT RELATED AUTHORS

L. Dubé and A. Bourhis:

CoPs are comprised of the three following foundational elements:

The basis of knowledge expansion is through discussion and collaboration of

EDUCATION THEORY 

Education Theory Made Practical: Volume 1  

Teresa M. Chan, MD, MHPE 

Chapter 2! Naturalistic Decision Making 

Chapter 3! Communities of Practice 

Chapter 4! Emotional Intelligence 

Chapter 5! Social Constructivism 

Chapter 6! Reflective Practice 

Chapter 7! Self-Directed Learning 

Chapter 8! Bloom’s Taxonomy 

Chapter 9! Dual-Process Reasoning 

Chapter 10! Gaming and Gamification 

Chapter 2! Naturalistic Decision Making 

Chapter 3! Communities of Practice 

Chapter 4! Emotional Intelligence 

Chapter 5! Social Constructivism 

Chapter 6! Reflective Practice 

Chapter 7! Self-Directed Learning  

Chapter 8! Bloom’s Taxonomy 

Chapter 9! Dual Process Reasoning 

Felix Ankel, MD 

1. Klein G. Naturalistic Decision Making. Human Factors 2008;50(3):456-460. 