Adult Learning Theory: A History and Application of Self-Directed Learning in Medical Education
The Emergence of Adult Learning Theory in the United States Adult learning theory is intrinsically rooted in humanistic psychology, or humanism, one of the "traditional" learning theories, made popular by humanists such as Abraham Maslow and Carl Rogers in the mid-1900s. However, it wasn't until the late twentieth century that the first systematic formulation differentiating between children and adult learners was proposed by Malcolm Knowles in the United States (Merriam and Bierema, 2013, p.46). It was in the 1980s that Knowles defined the method and practice of teaching adult learners as andragogy. Though the term was originally used in Germany by Alexander Kapp in 1833, it was first promoted by Edward Lindeman in the United States in 1926. It was from Lindeman that Knowles drew inspiration from, recognizing a series of "assumptions" about adult learners that was unique to them. Knowles initiated four primary assumptions in 1980, and two more in 1984:
As a person matures, his or her self-concept moves from that of a dependent personality toward one of a self-directing human being.
An adult accumulates a growing reservoir of experience, which is a rich resource for learning.
The readiness of an adult to learn is closely related to the developmental tasks of his or her social role.
There is a change in time perspective as people mature - from future application of knowledge to immediacy of application. Thus, an adult is more problem centered than subject centered in learning.
Adults are mostly driven by internal motivation, rather than external motivators.
Adults need to know the reason for learning something (Merriam and Bierema, 2013, p.47).
Besides the foundational theory of andragogy, three other main theories exist to explain adult learning: self-directed learning, transformative learning, and experiential learning. The first of these was explicated by Knowles himself in 1975 as a process "in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating those learning outcomes" (p. 18). The second and most studied, transformative learning, has been said to replace andragogy as the most popular educational philosophy in adult education, with evidence and research to back its teaching practices. In 2000, Mezirow claimed that transformative learning was a "process by which we transform our taken-for-granted frames of reference (meaning schemes, habits of mind, mindsets) to make them more inclusive, discriminating, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide actions" (p.8). It is within transformative learning that students use critical thinking to question beliefs and reconsider their current perspectives. Finally, the theory of experiential learning has arguably been discussed since the fourth century B.C., but John Dewey succinctly explained the view in the 1900s: "What [one] has learned in the way of knowledge and skill in one situation becomes an instrument of understanding and dealing effectively with the situations which follow. The process goes on as long as life and learning continue" (1963, p. 44). Essentially, experiential learning is a cycle in which someone experiences something, reflects on it, analyzes it and comes to conclusions, which are then tested in future situations. Self-Directed Learning Within self-directed learning, four types of projects were identified by Alan Clardy in 2000: induced, synergistic, voluntary, and scanning. Induced learning is that which is mandated by an authority. The learner would have no mastery of the information and would be considered "unconsciously incompetent" in the area. Conversely, voluntary learning entails "conscious competence" and is used to achieve a goal that is "not motivated or validated by a higher authority" (Merriam and Bierema, 2013, p. 64). Synergistic learning is optional, done "consciously incompetently," and occurs when one takes advantage of an available, but nonobligatory, learning opportunity. Finally, scanning learning is an ongoing process of education. Self-directed learning naturally arises when a learner takes charge of their education with four goals in mind. The first is the aspiration to gain knowledge or develop a skill. Certainly, the second involves becoming more self-directed in their learning. Another goal is to inspire transformative learning and critical reflection, and ultimately to be "emancipatory, supporting social justice and political action - moving beyond the realm of individual learning" (Merriam and Bierema, 2013, p. 64-5). Self-Directed Learning in Medical Education Medicine, and consequently its knowledge base, is changing at such a rapid pace with more and more research being performed to lengthen human lives and increase the quality of them, that learners in medical education cannot afford to not continue to learn throughout their professional careers. As such, it is virtually imperative that learners (and educators) in the field embrace self-directed learning, especially when one considers the standing demands of their professional and personal lives. Towle and Cottrell (1996) identified not only learning activities, but course features that enhance self-directed learning. Students should possess time management skills, set their own learning goals, identify and select appropriate learning resources and strategies, select the important from the unimportant, integrate material from different sources, monitor the achievement of learning outcomes, and monitor the effectiveness of their own study habits (p. 357). Program can aid their learners in their efforts by implementing the following course features:
Clear, advance information about tasks
Specific performance goals for assignments
Intrinsic rewards for task completion
Timetabling that allows sufficient time for task completion
Trust that learners will remain on task
Support for student learning, for example, personal tutors, study skills courses
Formative assessment and feedback that enables students to monitor and modify their own learning
Appropriate summative assessment, that is, that tests problem solving rather than rote repetition of facts
Appropriate staff development/teacher training (Towle and Cottrell, 1996, p. 358)
These basic tenets of self-directed learning are appropriate for all levels of medical education, both formal and informal, undergraduate and graduate. The Accreditation Council for Graduate Medical Education, or the ACGME, makes a point of this by asking that their trainees "continuously improve patient care based on constant self-evaluation and lifelong learning" (Accreditation Council for Graduate Medical Education, 2018, p. 20) as one of their practice-based learning and improvement goals within their core competencies. The Evolution of Adult Learning Theory in the Next Decade Though the current adult learning theories will likely have application long into the future, the invention and subsequent boom of technology such as the Internet, applications, and smart devices require educators to evolve with their learners. Petrucci et al. (2017) promote the learning theory of connectivism, or the idea that "people learn through sharing information across the World Wide Web using internet technologies" (p. 245), to explain the need for surgical educators to turn to social media to cater to the needs of the influx of the millennial generation of trainees and "eventually incorporate these sites as an integral part of medical and surgical education" (p. 250). This theoretical framework has its origins in social constructivism and unquestionably relies on the exchange of external and internal information. However, connectivism allows for communities who previously could and would never interact to be able to do so easily, increasing one's knowledge exponentially. In future, Diug et al. (2016) recommend further research to "identify effective methods implementing social media interventions in education" and to "develop guidelines to promote e-professionalism and use of social media within the field of medical education" (p. 228). References: Accreditation Council for Graduate Medical Education. (2018). ACGME Common Program Requirements (Residency). Retrieved from https://acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf Dewey, J. (1963). Experience and education. New York: Collier Books. First published 1938. Diug, B., Kendal, E., & Ilic, D. (2016). Evaluating the use of Twitter as a tool to increase engagement in medical education. Education for Health, 29(3), 223-30. doi: 10.4103/1357-6283.204216 Knowles, M. S. (1975). Self-directed learning: A guide for learners and teachers. New York: Association Free Press. Merriam, S. B., & Bierema L. L. (–). Adult learning: Linking theory and practice. San Francisco, CA: Jossey-Bass. Mezirow, J., & Associates. (2000). Learning as transformation: Critical perspectives on a theory in progress. San Francisco, CA: Jossey-Bass. Petrucci, A., Chand, M., & Wexner, S. (2017). Social media: Changing the paradigm for surgical education. Clinics in Colon and Rectal Surgery, 30, 244-51. doi: 10.1055/s-0037- 1604252