1. The document discusses several learning theories that are relevant to clinical teaching, including adult learning theory, social learning theory, situated learning theory, and reflective practice. 2. It emphasizes that adult learners are more self-directed and learn better when new information is connected to their experiences. Clinical teachers should facilitate internal motivation and self-directed learning. 3. Social learning theory and the concept of "communities of practice" are discussed, highlighting how learners observe role models and learn from participating in authentic tasks and discussions with experts. 4. Situated and reflective learning theories suggest learning is most effective when learners can actively participate in real clinical scenarios and reflect on their experiences individually and through group discussions.

1. 1
Learning Theories
Hirotaka Onishi MD, MHPE, PhD
Dept of International Cooperation for Medical Education
International Research Center for Medical Education
Graduate School of Medicine, University of Tokyo

2. Dr. A
I worked very hard to prepare for this lecture,
but many students were lazy enough to sleep.
I should have used the preparation time for my
presentation in the conference next week.
Students nowadays do not have serious
attitude to learn anything.

3. Students’ Comments for
Dr. A
The voice of Dr. A’s lecture is too small to
listen. Learning materials are not
organized nor sophisticated.
We should have been absent if we know
he does not take attendance!!

4. Dr. B
When I was young, senior doctors said that
clinicians have to learn by stealing.
Nowadays young clinicians do not have such
a spirit, so I teach at bedside and corridor
regarding diagnostic reasoning by mini-
lectures.
My mini-lecture is 30 minutes long and they
seem to become full stomach by knowledge.

5. Students’ Comments for
Dr. B
Once Dr. B begins to talk, it tends to be
very long. We have to listen to his talk
quietly, otherwise, he might be angry.
In 5 minutes we understand what he
wants to say but it will be very time-
consuming and waste of time.

6. Is Your Current Teaching
Appropriate?
 Reflect on your teaching practice
 Discuss how you can improve yourself
 What is your basis to determine the
appropriateness of current teaching?

7. Basis for Best Teaching
 How role-model teacher is doing
 Theory for teaching and learning
Both practice and theory is important
Theory is useful to analyze practice
critically

8. Difficulty in Teaching
 Imagine “patient education”
 Needs assessment of patient
 Amount of info
 How can you assist them?
 Teaching = Communication
with an inter-culturally different
person
 LEARN approach: Listen, Explain,
Acknowledge, Recommend,
Negotiate (Berlin & Fowkes)

9. Learning Theories
1. What is learning?
2. Adult learning theory
3. Social learning theory
4. Situated learning
5. Reflective practice

10. 1. What is Learning?
 Some studied hard but work ability is low.
 Some did not show high mark but work much.
 I am still not confident with my physical
examination ability…
 How can I learn medical interview skills?
 How can I learn to become a master of
clinical practice?

11. Meaning of Learning
 Connect new information to old
basic knowledge or principles
 Adapting themselves to the
situation
 Behavioral change
 Becoming a life-long learner

12. How Much of Learning Will
Remain in Memory?
National Training Laboratories, Bethel, Maine, USA
Remaining
in Memory
5%
10%
20%
30%
50%
75%
80%
Lecture
Reading
AV Material
Demonstration
Group Discussion
Practical Experiences
Teaching someone
Passive
learning
Active
learning

13. Cone of Learning
（Edgar Dale）
Read text
Listen to lecture
Watch still pictures
Watch moving pictures
View exhibit
Watch demonstration
Participating in discussion
Role-play a situation
Model or simulate a real experience
Go through the real experience
Verbal receiving
Visual receiving
Receiving &
Participating
Doing

14. What Should We Learn?
 Intellect in the experts?
 General truth?
 Truth in one’s self?
 How to adhere to the rule required in
the workplace?
 Ability and/or moral framework
demanded from the community?

15. Various Learning Modes
Conditional Reflex
 Pavlov’s dog
(Stimulus-
Responses
Relationship)
Behaviorism--all behaviors are either reflexes produced by a response
to certain stimuli in the environment or a consequence of that
individual's history, including especially reinforcement and punishment

16. Cognitivism
 An information-processing psychology
derived in part from earlier traditions of the
investigation of thought and problem solving.
 Concepts of motivation, attention, hypothesis,
etc. became able to be discussed.
 Constructionism： learners construct mental
models to understand the world around them.

17. Contextual Learning
 Cognitive activity is aggregated actions
in various situations/contexts.
 Practical training in clinical settings
happens in different contexts/situations.
 At that time, learners might feel
theoretical framework do not fit with the
real world and should “unlearn” pre-
existing knowledge.

18. 2. Adult Learning Theory
 As learners grow up, characteristics of
learning change:
 Based more on experiences,
 Related more with social roles,
 Oriented to self-directed needs, and
 Aimed at one’s goals.
 Clinical teachers should stimulate these

19. Develop Independent
Learners
 Give a man a fish and you feed him for
a day. Teach him how to fish and you
feed him for a lifetime (old Chinese prov.)
授人以鱼只救一时之急
授人以渔则解一生之需
 Sustainability is the key!

20. Meaning of Adult Learning
 Teachers’ responsibility for adult education is
to develop self-directed learners.
 It is important to let learners to build up new
theories and information on their
experiences.
 Teachers usually have to watch and wait
until learners decide needs, objectives,
strategies and assessment by themselves.
 Teachers should pay attention to and
facilitate learners’ motivation.

21. Motivation & Learning
 External motivation
 If you take 80%< in the exam, I will buy a laptop
computer for you – reward
 If you are the worst of five residents, you won’t
take a long leave – punishment
 Internal motivation
 After I learned to how to differentiate the murmurs
of AS from MR, I try to increase the opportunities
to listen to the heart sound – curiosity
 I must learn how to treat TB because he is my
patient – responsibility, self-directedness

22. External or Internal?
 External motivation
 Easier to arouse
 In the beginning it can work, but after
that the effectiveness will decrease.
 Internal motivation
 Typically it can work longer
 External  Internal
 “The resident was told to read a copy of an article,
but he found it very interesting and tried a short
presentation to peers about the disease”

23. Keller’s ARCS model
- How to Control Motivation -
 Attention
 Arouse and maintain curiosity/attention
 Relevance
 Connect classes and objectives/demands
 Confidence
 Enhance confidence to success
 Satisfaction
 Manage enforcement/motivation

24. Hierarchy of Needs (Maslow)
 Lower conditions are
required to achieve
higher goals
 Important to maintain
a suitable learning
environment
Self-
actualization
Esteem
Love and belongingness
Safety
Physiological

25. 3. Social Learning Theory
 Watching how a role model behaves
has strong (positive/negative) impact on
the future behavior
Ex) In the class a clinical teacher mentioned
importance of empathic communication
between Dr & Pt, but a student saw the
teacher scalded a Pt in the clinic.

26. Children See, Children Do
 https://www.youtube.com/watch?v=5Jrt
pCM4yMM

27. Curriculum Viewpoints
 Not only schedule or program but also what
learners learned should be considered
Manifest curriculum
Hidden curriculum
What teachers
like to teach
What learners
actually learned

28. Analysis for Environmental
Factor
 Observational learning includes both positive
and negative learning
 If a teacher’s advice and behavior conflicts
with each other, impact of observed behavior
is much stronger.
Ex) A doctor often explains to his
patients that good sleep,
balanced food, and exercise
are the keys for healthy life,
but he works too hard to
maintain his health.

29. Scene 1
A student saw a pneumonia patient at ER.
She determined antibiotics by the Gram stain
result. The patient was taken over to an
internal medicine preceptor and three days
later became afebrile. When the preceptor
came across the student in the hospital hall,
he gave her a feedback that the choice of
antibiotics was appropriate and the patient
became better.

30. 4. Situated Learning
 Firstly tailor trainees learn how to sew buttons
（Lave & Wenger）
 Basic technique but importance is not low
 If failed others can redo the button sewing
 Community of practice is emphasized and novice
should participate and contribute Legitimate
peripheral participation
 “Learning by doing” is a powerful method.

31. Surgeon’s Assistant
 If students do not understand the operation
very well, they are not so interested in
observation.
 If students are asked a few question about
location of an artery or a muscle, they will
be motivated

32. 4. Reflective Practice
 Formal theory for professional is often not
useful to the solution of the real life “messy,
indeterminate” problems of practice (Schön)
 Unexpected events or surprises trigger two
kinds of reflection
 Reflection in action: thinking while problem solving
 Reflection on action: thinking after problem solving

33. Experiential Learning
 Kolb’s learning cycle
Learning at ER
 P: Differential Dx from
a chief complaint
 E: Interview under
supervision
 R: Case presentation
 T: Reviewing lessonsTheory
Experience
Planning
Reflection

34. Promoting Reflection
 Reflection-in-action
 How should I rule out bronchial
asthma by physical examination?
 Reflection-on-action
 Forced exhalation will increase the
sensitivity of bronchial asthma

35. Reflection-in-Action in
Medical Interview
 Medical students often notice:
 Differential diagnoses of LLQ pain for
young and single lady?
 How should I ask psychosocial issues?
 If a new lesson was written down, it
will be a trigger to improve.

36. Reflection-on-Action and
Preparation for Presentation
 Students often notice what should
have been done while preparing case
presentation
 Differential diagnoses were incomplete.
 I missed one item of abdominal exam.
 Sufficient reflection-on-action during
preparation for case presentation will
help improve reflection-in-action for
next similar patients

37. Technical Mastery vs Reflective
practice (Schön & Argyris)
Decision-
making rules
Mental
Model
Real world
 Single-loop learning: the repeated attempt at the same problem,
with no variation of method and without ever questioning the goal
 Double-loop learning: used when it is necessary to change the
mental model on which a decision depends
Decision
Information
feedback

38. Ex) Quality Improvement of
Physicians in Laos
 WHO found that physicians’ diagnostic
reasoning ability is low in Laos.
 WHO produced a therapy/management book
directly from signs/symptoms.
 Experts in Laos are shocked with many cases
of misdiagnoses.
 What is the evaluation result of the therapy/
management book?

39. How to Facilitate
Reflective Practice
 Ask questions for past experiences or
theoretical framework
 Tools for reflection by oneself
 Portfolio/reflective journal
 Conference or meeting
 Mentoring or discussion

40. Group Work
 Decide a moderator and a presenter
 Each member talks about the best
teacher he/she has ever met one by
one
 After all members finished, anyone can
add other episodes or whatever
 The presenter will present the core
idea of “best teacher”