Authors: Anita Thomas, MD, MPH, Brian Barbas, MD
Editor: Benjamin Schnapp, MD, MEd

A Case

It is a busy Sunday evening in your emergency department. Jared, a fourth year medical student, is completing his case presentation to Dr. Jones: “…so, in assessment, Sarah is a 2-year-old female with a 2 cm linear forehead laceration, that I think requires suture repair.”

“Sounds good,” Dr. Jones replies. Since she has never worked with Jared before, she asks, “Do you feel comfortable suturing?”

“Definitely, I’ve sutured a bunch on other rotations,” Jared replies.

Dr. Jones nods. She has two other learners to check in on and patients are piling up in the waiting room. She decides to trust Jared’s self assessment. “Okay, I’ll order the topical anesthetic, intranasal midazolam, and have the nurse administer the midazolam about 5 minutes before we go in.”

Dr. Jones then sees several other patients and realizes that it has been about 45 minutes since topical anesthetic was applied to Sarah’s laceration. She walks into the patient’s room just as the nurse is administering intranasal midazolam and Jared is setting up the laceration tray. After restraining Sarah and attempting to distract her with her parents’ phones, it becomes apparent that Sarah was not sedated sufficiently, resulting in her screaming throughout the procedure. Her parents are very distressed, intermittently in tears and angry with the whole healthcare team.

“He told us that she would be completely asleep!” Sarah’s parents exclaim, pointing at Jared.

Dr. Jones attempts to de-escalate the situation by highlighting the amnestic effects of midazolam and remarks that Sarah likely does not like being restrained. She reiterates that this is a common anxiolytic in this age group for this procedure and that she does not typically recommend full sedation for this type of procedure.

While Dr. Jones is talking to Sarah’s parents, Jared starts to irrigate Sarah’s laceration, causing Sarah to cry even louder. At this point, Dr. Jones says, “I think it might be better if I did the repair.”

Jared is confused, but he pushes the laceration tray towards Dr. Jones. He watches the rest of the procedure silently, annoyed and feeling out of place.

After the laceration repair, Dr. Jones rushes out of the room to see another patient. Jared lingers with Sarah and her parents, discussing post laceration repair care. After several minutes, he steps out of the room to grab a popsicle for Sarah. He plans to discuss what happened, but by the time he had a moment to grab Dr. Jones, she had left for the day. Both of them were left wondering how the situation could have gone better.

Overview

As the name suggests, Kolb’s theory of experiential learning posits that much of learning takes place as we make sense of the experiences that we have. The four steps of Kolb’s theory are: concrete experience, reflective observation, abstract conceptualization, and active experimentation. Learning processes that are directly across from each other on the learning cycle (Figure 1) are related. Concrete experience and abstract conceptualization can be viewed as grasping experiences whereas reflective observation and active experimentation as transforming experiences.¹ 

Figure 1: A graphical depiction of Kolb’s learning cycle, with the arrows indicating the traditional order of each step.²

Background 

While first published in 1984 by educational theorist David A. Kolb, the influences behind experiential learning theory (ELT) can be found in the works of many before him including John Dewey, Kurt Lewin, Jean Piaget, and many more.

The concept of experiential learning can be seen as far back as the teachings of Confucious around 450 BC: “Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand.”³ In the early 20^th century, this concept took hold in modern educational theory. During this time period, psychologist John Dewey posited that “there is an intimate and necessary relation between the process of actual experience and education.”⁴

During the 1940s, while studying group dynamics, social psychologist Kurt Lewin and his colleagues made note of the experiential learning process at work. While exploring the conversation about “the differences of interpretation and observation of the events by those who participated in them,” Lewin observed that learning is best facilitated in a setting in which there is an active balance between immediate concrete experiences of learners and the detached analytic feedback of the group.¹ This lead to the creation of the National Training Laboratory in Group Development, which inspired the learning cycle at the base of Kolb’s ELT.¹

Meanwhile, Piaget’s work exploring the cognitive-development process in childhood led to the development of another learning theory. Through his studies, Piaget argued that “intelligence arises as a product of the interactions between the person and his or her environment.”¹ In other words, as Kolb summarized Piaget’s work, “intelligence is shaped by experience.”¹

Modern Takes on this Theory

Experiential learning is essential to all of medical education. Nearly all of residency is an experiential learning process involving concrete experience, reflective observation, abstract conceptualization, and active experimentation under supervision. Kolb’s theory is so ingrained within medical education that most literature on practical application of Kolb’s ELT is related to clinical applications. Every patient interaction, new procedure, and bedside teaching moment with a medical student is an opportunity to witness Kolb’s ELT in action. Multiple times in a shift, a residents has a concrete experience, reflects on the experience, thinks of a plan to improve, and applies the changes on the next similar experience. In studies of resident education, Kolb’s ELT serves as at least a partial explanation for what is retained, highlighting the importance of trainees’ patient encounters.^5,6

Other Examples of Where this Theory Might Apply

Clinically: Kolb’s theory of experiential learning can be applied to almost any patient encounter, but clinicians (including medical students, residents, and fellows) must actively engage in the steps. Reflection may be more likely after recognized medical errors, but the goal is for it to occur after almost every patient encounter. For example, a trainee might attempt to reduce a pediatric nursemaid’s elbow, which was actually been a supracondylar fracture. Discovering this on x-ray may lead to reflection and abstract conceptualization of why this patient had a fracture rather than a nursemaid’s elbow. Active experimentation would occur as they create their treatment plan for their next pediatric patient with elbow pain. 

Classroom: Kolb’s theory applies well to the simulation environment. Simulated patient scenarios provide a concrete experience. Debriefing encompasses reflective observation and abstract conceptualization. Debriefings often start with open-ended questions such as “How did that feel?” allowing for the group to begin the process of reflective observation while discussing the most salient points of the case. Reviewing and reflecting on that shared experience ideally results in abstract conceptualization. For instance, a facilitator may start a discussion with, “Tell me about how you were thinking about whether to give fluids for this patient,” which can lead to a shared mental model of why fluids were desired and in what quantity. Active experimentation, or trying out variations on what was learned, can then be accomplished in subsequent simulations and in real patient encounters. Simulation can allow for all four steps of Kolb’s theory in quick succession by stopping participants when an error is made, offering immediate time for reflection and learning (which is not generally present in the real clinical environment), and repeating the simulation from the beginning so that active experimentation with new knowledge can be put into practice right away, a technique called rapid cycle debrief practice.⁹ 

Additionally, Kolb’s theory can be applied to morbidity and mortality (M&M) conferences, which start with a concrete clinical experience that has an unanticipated outcome, then allows for reflective observation and abstract conceptualization about more ideal management with the group. For example, if a patient with a headache after a concussion was ultimately diagnosed with a brain tumor after several clinical visits, the case serves as a surrogate concrete clinical experience for the primary clinician. Specifics of each visit, including the history, exam, and decision making, are generally reviewed during the conference, thus creating a shared mental model for all attendees. Generally, groups then reflect on each visit and discuss the clinical scenario. Often, other clinicians will utilize abstract conceptualization with comments like “Well, if I had been the primary doctor, then I may have ordered head imagine because of multiple visits,” or “I probably would have treated the patient similarly because of lack of concerning symptoms.” The purpose of M&M conferences is to reflect and increase awareness of such cases, such that attendees keep them in mind and potentially change their behavior when seeing similar patients in the future — a perfect example of active experimentation.

Kolb can be utilized as a framework for workshops as well. Structuring workshops with breakout sessions allows participants to reflect on their concrete experience. It also provides time to apply concepts learned during the workshop and conceptualize ways to change/improve their practice. Depending on the workshop topic, a workshop may allow for active experimentation as well. For example, in a quality improvement workshop, participate could be asked to reflect on quality issues the have experienced (concrete experience), think about how they have been addressed (reflective observation), consider what makes for a successful quality improvement project (abstract conceptualization), and brainstorm an opportunity for improvement in their own clinical environment (active experimentation).

Limitations of this Theory

It can be difficult to accomplish all of Kolb’s stages in a real clinical environment as it requires deliberate reflection and repeated experiences. In an emergent situation, like performing CPR on a dying patient, there might not be time to guide a learner through reflection, conceptualization, and experimentation. Additionally, the goal for a learner would be for the Kolb cycle to be self-sustaining, but the cycle does require some level of intrinsic motivation unless there is an external facilitator. For a trainee who is burned out, Kolb’s theory may not be relevant as the learner may not have the capacity to tackle a multi-stage learning cycle.

Additionally, while Kolb’s learning cycle shows a continuous progression, in reality, different stages might occur out of order or simultaneously, which can be difficult to predict. It may be useful to lay out Kolb’s learning theory when engaging with a trainee to employ a shared mental model for learning, such as how to approach a new procedure. 

Lastly, Kolb’s ELT does not consider the social context of the learning, including power dynamics between teachers and learners.¹¹ If a medical student is fearful of being reprimanded in front of the entire team, they may be less open to sharing experiences or open reflection. Additionally, it does not take into account racial- or gender-based dynamics. A female intern of color might have a different concrete experience than a white male intern. Effects of prior learning experiences are called out in Kolb’s ELT, but they play a large role in shaping learning for a trainee. For example, a learner who has already seen many patients with chest pain during their rotation will have different experiences and reflections than a learner who has seen relatively few patients with chest pain.

Returning to the case…

A few days later, Jared returns for another shift and eagerly picks up another facial laceration case, this time with a 3-year-old patient.

“Hi Dr. Jones, I have a 3-year-old male with a 2 cm forehead laceration that needs repair. I’ve already discussed intranasal midazolam use with the family and the nurse applied the topic anesthetic. I feel comfortable repairing with your supervision.”

Dr. Jones nods and gestures towards Jared to sit. “I’ve been thinking about the laceration we had together a few days ago.” She wanted to use this clear concrete experience as a discussion point with Jared. Aiming to open the door for reflective observation, she asks Jared: “How did that feel to you?”

“It was really stressful for me because I felt like I didn’t get a chance to try,” Jared replies.

Dr. Jones asks, “What could I have done to help you?”

“Well, I would have liked to have at least tried more than irrigating. But, I don’t think I prepared the family well enough for the sedation. I thought we would knock the kid out! I think I started out on the wrong foot with the family and it seemed like you took over because they were upset.” 

Dr. Jones notes that this is a powerful reflective observation. Dr. Jones stands up and motions for Jared to walk with her to the procedural practice area. “I think one part of the issue is that I did not assess your familiarity with the types of sedation we use for pediatric procedures. What I discussed with the family when they were upset is typically how I prepare them for intranasal midazolam use.” (Dr. Jones reflectively observes and initiates abstract conceptualization)

“Yeah, it was useful to be there for that discussion and I used it to model how I spoke to the patient’s family today.” Dr. Jones nods, noting that today’s patient is a concrete experience where Jared can engage in active experimentation.

“That’s good to hear,” Dr. Jones replies. “Let’s walk through your approach in a pediatric patient. We can practice the procedure on this practice suture pad. We can discuss how I prepare families for the repair and when it would be appropriate for me to intervene.” 

As they walk through laceration repair, Dr. Jones spends five minutes reviewing her laceration repair checklist with Jared in an effort to engage in abstract conceptualization.

“I hope that was helpful,” Dr. Jones says as they walk back over to the work area.

“To be honest, at first I didn’t think I actually needed to review laceration repair, but I see how it can be different in a pediatric patient. I do feel more prepared and am excited to do this one, but understand clearly when you would need to intervene.” Jared replies. Dr. Jones notes again that Jared is engaging in more reflective observation.

“Okay, gather your supplies, and come grab me when the nurse has given intranasal midazolam and we can do this laceration together,” Dr. Jones states to Jared. She hopes that prepping Jared will not only set him up for success, but also make for a better experience for the patient and family. They are both, in a way, engaging in active experimentation – Jared in his laceration care, and herself in terms of her supervision of trainees.

References

1. Kolb DA. Experiential learning: Experience as the source of learning and development. Prentice-Hall; 1984.
2. Kolb DA, Boyatzis RE, Mainemelis C . Experiential learning theory: Previous research and new directions. In R. J. Sternberg & L.-f. Zhang (Eds.), Perspectives on thinking, learning, and cognitive styles. Lawrence Erlbaum Associates Publishers; 2004:227-247.
3. Pickles T, Greenaway R. Experiential learning articles + critiques of David Kolb’s theory. Reviewing.co.uk website. http://www.reviewing.co.uk/research/experiential.learning.htm#ixzz5ws8QAc1s. Accessed 17 Aug. 2019.
4. Dewey J. Experience and Education. Simon and Schuster; 1938.
5. White JA, Anderson P. Learning by internal medicine residents: Differences and similarities of perceptions by residents and faculty. J Gen Intern Med. 1995;10(3):126-132. 
6. Chung PJ, Chung J, Shah MN, Meltzer DO. How do residents learn? The development of practice styles in a residency program. Ambul Pediatr. 2003;3(4):166-172.
7. Ha CM, Verishagen N. Applying Kolb’s learning theory to library instruction: An observational study. Evid Based Libr Inf Pract. 2015;10(4):186.
8. Healey M, Jenkins A. Kolb’s experiential learning theory and its application in geography in higher education. J Geog. 2000;99(5):185-195. 
9. Lemke D, Fielder EK, Hsu DC, Doughty CB. Improved team performance during pediatric resuscitations after rapid cycle deliberate practice compared with traditional debriefing: A pilot study. Pediatric Emergency Care. 2019,35(7):480-486.
10. 10. Kolb DA. Experiential learning: Experience as the source of learning and development. 2nd Edition. Pearson Education, Inc; 2015. 
11. Yardley S, Teunissen PW, Dornan T. Experiential learning: AMEE guide No. 63. Medical Teacher. 2012;34:102-115.