© 2003 American Thoracic Society
Education Theory Applied to Critical CareDewey versus Tradition: It Really Does MatterMayo Multidisciplinary Critical Care Fellowship Mayo Foundation Rochester, Minnesota The education of residents and fellows in critical care has long had an experiential base. Traditionally, work hours have been long and call nights frequent, reflecting the importance of clinical experience in fostering effective learning. The conventional approach to residency education has been likened to apprenticeship; "see one, do one, teach one" has long echoed in the halls of great American institutions. However, work-hour restrictions, legal disputes, financial concerns, and generational differences are reshaping how we teach critical care. We are under increasing pressure to do more with less. We must create new, cost-effective ways to produce a measurable competence in student performance. In this issue of AJRCCM (pp. 32–38), Cox and coworkers (1) provide new insights into an apparently common deficiency within U.S. internal medicine residency programs—that of suboptimal learning related to mechanical ventilation. Senior internal medicine residents tested near the end of their training had serious knowledge deficiencies on the subject, specifically in areas of literature-established best-practice norms (e.g., low tidal volume management of patients with acute respiratory distress syndrome [2]). The test results consolidated the fact that closed intensive care units, known to produce better clinical outcomes (3–7), provide a better environment for learning than the open variety—the type that unfortunately makes up the majority of the intensive care units in the United States (8). Adverse patient outcomes are the likely and logical result of these knowledge gaps. These deficiencies pose serious clinical and educational challenges. Demographics of increasing numbers of patients requiring intensive care unit care, combined with decreasing numbers of trained intensivists, will mean large and increasing critical care provider deficits at the national level. The current ratio of supply to demand is forecast to remain in rough equilibrium until 2007. Subsequently, demand will grow rapidly while supply will remain nearly constant, yielding a shortfall of specialist hours equal to 22% of demand by 2020 and 35% by 2030 (9). The findings of Cox and coworkers raise serious concerns as to whether general internists, as currently trained, are truly competent to fill these gaps (1). Note that 84% of residents in this study said that they would or might care for ventilated patients in their future careers. As pointed out by the authors, an equally troubling fact is that the majority of hospitalists in America are represented by the internal medicine training pool. In the study by Cox and coworkers, resident satisfaction with mechanical ventilation–related learning correlated strongly with the presence of learning objectives, which were present in only 27% of programs (1). Ninety-two percent of internal medicine residency directors felt that residents in their programs were competent (in knowledge-base) to provide mechanical ventilation; sadly, only 44% of residents agreed. The real problem here is a conflict of learning theory. Education theory comprises two major constructs (10). The first is best exemplified by a professor lecturing to an overcrowded lecture hall of college students expected to acquire knowledge of every phrase uttered for some future examination. This is the "traditional" construct of teacher-oriented education. In this example, which many of us encountered in undergraduate years, an assumption made is that "cream always rises," that it doesn't matter how well information is packaged and delivered—only content matters. At the graduate medical educational level, students are expected to implement self-directed learning, filling in curriculum gaps independently. Residents in the aforementioned programs (with overly optimistic program directors) are expected to search the literature and rise like the proverbial cream. Educational theory's competing paradigm, first articulated by John Dewey in the first half of the last century (11), is a learner-oriented experiential construct. In this view, learning, not teaching, is of paramount importance. Learning objectives, as espoused in the conclusions of the Cox article, therefore are critical. Resident learners are not assumed to rise (like cream) as self-directed learners are (e.g., filling the gaps in mechanical ventilation instruction). In the Dewey model, in contrast to traditional methods of didactic instruction, the way in which information is packaged matters. Experiential learning requires forethought based on curricular goals. Creative avenues (e.g., mechanical ventilation workshops, simulations, and other group learning experiences) are woven artfully into the learning curriculum. Learning goals are matched with experiential learning plans because experience imprints knowledge more readily than didactic presentations (12). Of course, critical care is a "hands-on" specialty. Students must both understand and be able to execute physiologically sound mechanical ventilation management strategies. Residents must somehow learn to deftly integrate cognitive and manual skills necessary for creating order from chaos in the context of complicated resuscitations. In addition, they must learn to assess and prioritize details of case management in an increasingly aging population of critically ill patients. Nowhere in medicine is the integration of the art and science of medicine more necessary. Critical care resident education is loaded with experiential learning needs. In response, however, the way that most programs structure the experiential learning opportunities is insufficient. Perhaps because of the intrinsic experiential learning aspects of our apprentice-style educational traditions (on-call experience, "see one–do one–teach one," long work hours, and so on) we have been slow to identify and adopt "best practices" of modern education theory for fostering experiential learning. In the new age of shortened work hours and million-dollar plaintiff awards, however, we are caught between less experience at the bedside and imposed—albeit correct—goals of measurable clinical competence. To maneuver these straits requires a different educational experience. Perhaps Dewey is right. Mechanical ventilation workshops, clearly defined educational curricula, and simulation-based experiential learning centers may truly be on the near horizon for all in critical care training. Cox and colleagues have uncovered a troubling fact: the learning theory applied within many residency programs is obsolete. REFERENCES
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