Cognitive psychology perspectives on learning

Cognitive psychology research has demonstrated that by learning through participating in routine tasks and activities, concepts and activities are transformed into skilled performance that does not require conscious thought (compilation). Clinicians (and students) develop mental representations of cases—‘illness scripts’—and their clinical reasoning appears to involve both analytical and non-analytical processes (Eva 2005) (see Ch 7). New learning and/or transfer is necessary to perform new and/or non-routine tasks and has been the subject of much debate (for example, Norman et al 2005, Colliver 2004). There is agreement that success in solving one clinical problem does not predict success at solving another, even related, problem and there is recognition that this is due to context specificity. However while this recognition has influenced current assessment practices, it seems to have had less impact on clinical education more generally. One of the main ‘messages’ of this chapter is that it is necessary to develop a much fuller understanding and recognition of contextual factors in order to develop more effective clinical education practices and research.

Sociocultural perspectives

Sociocultural perspectives understand learning to result from individuals constructing their own knowledge as a result of participating in sociocultural activity, for example, a healthcare student undertaking a clinical placement. Learning is situated (that is, contextual, dependent on the social and physical environment) and opportunities to participate—legitimate peripheral participation (Lave & Wenger 1991)—are therefore essential for learning. However these opportunities (‘affordances’) are dependent on many factors including hierarchies, acceptability, personal relationships and workplace culture, and so may not be equal (Billet 2001). Learning is usually understood as a form of internalisation in more individual psychological explanations but Rogoff (1995, Rogoff et al 1995) argues that change resulting from participating in an activity (which the authors call ‘appropriation’) is a process of transformation and not simply internalisation.

There are weaknesses in both perspectives. Cognitive psychology does not fully explain how knowledge is sourced, represented or constructed or how social practices influence this construction, while sociocultural theories do not completely account for the construction of different types of knowledge or how it is used (Billet 1998). So, in clinical education, cognitive psychology can account for aspects of the development of diagnostic skills, for example, but not how they are influenced by different settings and interactions. Conversely, sociocultural theories do not fully address how underpinning knowledge (and its ‘accuracy’ or otherwise) about bodily systems, for example, are used in activities although they do address how participation in activity influences learning. Both cognitive psychology and sociocultural perspectives understand (albeit with different emphases) knowledge acquisition as active and interpretative. Learning is understood more as a process of becoming in sociocultural theories, while in cognitive psychology perspectives it is more understood as a process of making meaning. Arguably, cognitive psychology privileges learning as a process of acquisition and sociocultural theories as a process of participation. Clearly how learning (and knowledge) is understood will determine both how it is investigated and how clinical education is delivered. I am trying to develop a research perspective that can explore and understand learning in clinical settings as involving both processes of becoming and making meaning.

Existing work in social sciences

There is a persistent trend in clinical education research to look for differences between groups, often without any consideration of the basis for, meaning or significance of postulating such differences. I will take the example of gender differences, although many of these arguments also apply to the search for differences between ethnic groups. It is rare that research papers considering gender differences make any acknowledgement of the longstanding, sophisticated and extensive debates and empirical work about gender and sex differences in the social sciences. One example will suffice to illustrate this point.

Janet Hyde (2005) examined 46 meta-analyses of research into gender differences in psychology. She found that 78% of reported gender differences were small or close to zero; the exceptions were throwing (particularly after puberty), and some measures of aspects of sexuality and physical aggression. However, in medicine, there are persistent ideas and research reports which suggest there are gender differences in motivations and attitudes, differences in academic performance, differences in clinical skills and communication skills, and even that women practice medicine differently. Our literature review (Kilminster et al 2007a) found very little evidence to support such arguments and assumptions; there is a vast amount of work that often produces conflicting findings. We did find problems with some of the research methodologies, frequent failure to report effect sizes, and, of course, there is also publication bias against non-significant findings.

It is essential to remember that ‘[h]ow we interpret data about the relative educational performance of different groups will depend on our research focus, and on our assumptions about the social and psychological processes involved’ (Hammersley 2001, p 293). Furthermore, there is a strong argument that such research can be detrimental for women. Rosemary Pringle (1998) noted the trend in medical culture to exaggerate the ‘feminine’ qualities of women in communication, empathy and care; if women are considered to be good empathetic communicators this may confer short-term advantages over their male counterparts. However this may be a ‘double-edged sword’ that will ultimately restrict women to successful practice only as the ‘new human face of a humbler form of medical practice’. Similarly, in the conclusion to her review of meta-analyses (2005) Janet Hyde argued that ‘over inflated claims of gender differences … cause harm in numerous realms’ (p 590) and, furthermore, such claims are also not consistent with the scientific data.

Research that aims to discern essential gender differences is often predicated upon unquestioned essentialist assumptions about traits and complementary skills that justify and reinforce women’s subordinate position. Furthermore, the cultures and practices of all health professions are interrelated with the social contexts in which healthcare is delivered, so approaches aimed at isolating one factor, such as gender and communication skills, are likely to fail to identify, or explain, the complexities involved. In medicine, there is a lack of research and analysis into how male doctors are contributing to modern medicine that is indicative of the historically masculine context in which medicine is embedded—this is demonstrated by frequent reference to the ‘feminisation’ of medicine. It is female doctors who are researched as the ‘other’, whereas male doctors receive little attention. In the social sciences, gender is generally understood as a relation rather than a trait. Gender relations are maintained by the interaction of various processes at different levels; they are not fixed. Therefore future research will be best served not by assuming; or looking for sex differences, but by examining where gender becomes relevant and impacts on education, training, practice and career paths in healthcare.