Adaptive methods for bedside teaching: Integrating cognitive apprenticeship model and social cognitive theory to elevate workplace learning

You are an attending physician in an academic emergency department (ED). You run into another attending in the department as you both pick up breakfast before your shift. You discuss the challenges you have faced over the past week working with residents and medical students. A few days ago, you were working with a skilled junior resident who expressed a desire to practice her leadership skills before moving into her final year of residency. That day, however, you had a high volume of patients, many of whom needed critical care. You express guilt in not being able to provide her with more one-on-one feedback and coaching while on shift. Meanwhile, your colleague working on another team where senior residents are expected to function as a “preattending” observed that their senior resident was slow to evaluate patients. Your colleague states that later the resident disclose that he was feeling “burnt out” from caring for an overwhelming volume of boarding patients. You both wish there was better guidance in how to provide high-quality workplace teaching given the stressors inherent to the clinical environment. In recent years, the ED has seen an unprecedented number of boarding patients.1 Rising patient volumes can outstrip capacity even in well-resourced departments and can place a significant burden on already strained supervisors. Learner capacity and environmental resources can vary day to day and shift to shift. Since the Flexner report, the workplace remains an essential component of medical training.2 For the purposes of this discussion, we will use the term “learners” to refer to resident physicians, physician assistants, nurse practitioners, and medical students. The term “supervisor” will refer to attending physicians, that is, departmental faculty who supervise learners on shift. In the ideal state, the learner is engaged, and the environment supplies a mix of patient acuity and adequate ancillary staffing.3 However, supervisors and learners are often not presented with the ideal state. Workplace learning is a concept that describes learning through experience and remains a cornerstone of residency education.4 Cognitive apprenticeship is an educational theory that focuses on learning-through-guided-experience and proposes six teaching methods: modeling, coaching, scaffolding, articulation, reflection, and exploration.5-7 Social cognitive theory states that an individual's actions, functioning, and learning are the direct result of the continuous interaction between environmental factors, personal factors, and behavioral factors.8-10 Through the lens of medical education, one can consider this triad as the learner (personal factors), learning environment (environmental factors), and teaching method (behavior). Depending on the learner capacity and environmental resources, optimal teaching methods may vary. The proposed conceptual model uses “learner capacity” in lieu of “personal factors.” Many factors contribute to the learner's cognitive ability including baseline knowledge, skills, and attitudes (KSAs) as well as their emotional state. The emotional state can also contain many variables including their degree of mental exhaustion and feelings of burnout. All of these components interact to impact the learner's capacity to consume new information.3 Environmental resources in the workplace refers to the patient volume, patient acuity and mix, staffing (nursing, technologists, and the educator—i.e., supervising physician), testing availability/efficiency, supervising physician's ability to teach in context of patient management, and accessibility of consultants/follow-up resources. For the purposes of this paper, authors have made the following adaptations—environmental factors (supervising physician capacity, adequacy of staffing, patient volume/acuity/mix), personal factors (learner cognitive and emotional capacity), and behavioral factors (teaching method(s); Figure 1). The learning scenarios that follow provide suggestions on the teaching methods best employed depending on the perceived learner capacity and environmental resources. Each suggested teaching method is also presented as a clinical scenario in Data S1. The goal of exploration is to facilitate the learners' own autonomous problem solving.5 For a more novice learner, this facilitation might mean the supervisor establishes the educational goals but encourages the learner to develop intermediate strategies or milestones to achieve them. For more advanced learners, exploration might mean charging the learner with entirely establishing their own learning goals and their specific objectives. In this latter context, exploration can be thought of as the summative method of the cognitive apprentice model, as it integrates the acquired skills of coaching/modeling/scaffolding with problem-solving agency gleaned from articulation and reflection. As such, exploration is best utilized when the supervisor already has some insight into the learner's capacities (or has the time and resources to better understand the same). Similarly, exploration as a method works best when the learner is intrinsically motivated (and has sufficient baseline capacity) to guide his or her own educational inquiry. Modeling does not require the supervisor to produce anything de novo; it is simply the externalization of the supervisor's existing cognitive or procedural heuristic for consumption by the trainee. In other words, the trainee observes as the supervisor performs. This method also does not require additional investment by the learner and works especially well in cases where the learner's KSA and/or motivation may be low. Learning can be made more effective if the supervisor explicitly states his or her internal schema for the learner.11 Learning in this situation becomes passive but can be efficient and powerful. Coaching describes situations in which a supervisor directly observes (and provides feedback to) a learner throughout the learner's performance of a skill.5 The real-time feedback provided by the supervisor serves to identify gaps in the learner's performance as well as to guide learners to the agreed upon goal. Having a mutually agreed upon goal is imperative when using coaching. The learning goal should have well-defined borders (e.g., obtaining central venous access in a hypotensive patient). As the end goal can be easily understood, this learning method does not require high learner capacity or environmental resources. However, successful coaching requires reciprocity. It requires the learner to provide insight into their process and it requires the supervisor to provide real-time feedback/guidance. Next, it requires the learner to adjust course in accordance with feedback received. Articulation involves guiding the learner to verbalize their problem solving process. Collins12 proposes three ways to achieve articulation: inquiry, explanatory, and commentary. In inquiry, the supervisor asks the learner “why-questions” when discussing decisions that were made. For explanatory, the learner explains their thought process as they try to solve a problem. In commentary, the learner critiques and verbalize their thought process of an activity that they have already performed. This process requires the learner to have insight into their own thinking and for the supervisor to hone into the learner's thought processes to tease out inconsistencies or learning gaps. The externalization of the learner's thought process allows the learner to establish clinical schemas. Reflection is an optimal strategy when environmental resources are constrained but the learner has sufficient capacity to help guide the learning process. During reflection, the learner pauses and considers how their thinking and performance may compare to that of an expert or an ideal situation. Key to this teaching method is the introspection that must occur on the learner's level. Eliciting the learner's own perspective on their successes and failures can create a ripe environment for teaching. The learner owns and directs the process of self-improvement, with guidance from an expert. Because reflection requires time, introspection, and a safe space, it can sometimes be difficult to undertake during clinical time. However, simply identifying the need for reflection can be a good start point. In the demands of high-stress states, levels of burnout can be elevated. Reflection both during and after shift can help to mitigate the emotional fallout from these stressors.13 This is the ideal learning environment with an especially novice learner. In this case, consider utilization of the concepts of the zone of proximal development and scaffolding. The zone of proximal development references learning with the assistance of an expert. Use of the zone proximal development and scaffolding on shift can be resource intensive (when compared to other teaching methods), as it requires an understanding of two zones, the actual zone (current state of learner—i.e. current skill set), and potential zone (proximal state).14 The “actual zone” consists of an individual's prior knowledge and experience. The “proximal zone” consists of the gap between what the learner can do with support and what they can do independently. The teacher/supervising physician can explore the learner's current KSA and extrapolate what can be developed with their assistance.15 You and your colleague discuss and acknowledge institutional limitations as well as the limitations of your own capacity. You recognize that you must adjust your expectations as well as your teaching method depending on your learner and the learning environment. You and your colleague aim to balance patient needs and educational demands, while recognizing that we all function in complex and fluctuating circumstances. Adaptability, the hallmark of an emergency physician, now becomes the hallmark of the emergency medicine educator. Christie Lech: Initiating concept and design of framework for manuscript, drafting manuscript, critical revision of manuscript. Christopher Reisig: Drafting manuscript and critical revision of manuscript. Kaushal Shah: Drafting manuscript and critical revision of manuscript. Sara Zaidi: Drafting manuscript. Di Coneybeare: Senior author, initiating concept and design of framework for manuscript, drafting manuscript, critical revision of manuscript. The authors declare no conflicts of interest. Data S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.