Authors: Drew Kalnov, DO; Jennifer Whitfield, MD; Sophia Lin, MD
Editor: Abra Fant, MD, MS; Teresa Chan, MD, MHPE

A Case

“I’m worried about Paul’s scores, they are concerning and put him at risk to not pass boards.  I just don’t get it, he is a solid performer in the department”

Most of the faculty at the clinical competency committee meeting nod in agreement as they review the inservice exam scores.

“What can we do about it? He seems so clinically competent when caring for patients.  He always gets my pimp question about patients we are caring for correct and asks great follow-up questions. How can he be struggling so much on a test when he clearly knows the answers?” states another faculty member.

The committee chair comments “he probably needs to be placed on a corrective action plan to help him.  He probably needs to do more practice questions and a few practice tests.  If he can improve his score on a practice test in a few months then we can look at taking him off the plan”. 

Another member remarks “I’m not sure that is the answer.  I just pulled up his progress through the practice question bank, he has completed nearly 90% of the questions, far more than most of the other residents. He obviously needs test taking help, but I feel like there is more we can do to help bring out his knowledge in the testing setting.”

“Let me think about it a bit more,” added another faculty member, “but can you believe Peter’s score?! He can be awful to work with in the department, how did he score in the top 10%?” 

The case we presented is a common problem in student and resident training, a disconnect in one’s perceived knowledge, clinical competency and test taking abilities.  Often some of the highest performing learners in the clinical setting struggle to translate this to static questions and tests, while others excel in test taking but struggle to apply that knowledge in the clinical setting.  What education theory can help explain why many learners perform in this manner, and what are some methods that can be used to improve their performance across all assessment mediums?

Background

Situation cognition was first formally described in the mid-1980s as a result of collaboration between the Institute for Research and Learning, a multi-disciplinary think tank tasked with studying the process of learning and the XEROX Palo Alto Research Center.² However, its origins lie in earlier theories from a broad range of disciplines. These theories include phenomenological philosophy from philosophy, cultural-historical activity theory and ecological psychology from psychology, American pragmatism from education, enactivism from theoretical biology, embodiment from physiology, and situation semantics from linguistics. 

In their collaboration, Seely Brown and colleagues sought to determine if knowledge could be learned as a mental representation of a concept within an individual, independent of context, and whether or not this internalization is requisite in successfully mastering complex human behaviors. In their research, Seely Brown and colleagues liken the acquisition of knowledge to the acquisition of vocabulary as studied by Miller and Gadea. While a child can certainly learn words and their dictionary meaning without being exposed to use of these words in real-world conversations, this method is less efficient and less effective than learning these words in the contexts in which they are normally used. Seely Brown et al. also compare knowledge to tools. To achieve a full “implicit” understanding of a tool’s function and the settings in which it’s used, a learner must actually use the tool in situations it was designed to be used. A community develops amongst individuals who use a tool and from this, culture and a community of practice form. This culture also adds to the full conceptual understanding of a specific tool. Seely Brown and colleagues posit that students need exposure to knowledge being applied by real-life practitioners. Learners must also engage in “authentic activity,” both basic and more advanced situations. When attempts at translating authentic activity to activities that are more easily accomplished in a classroom, knowledge becomes limited to the domain of the classroom, making it less easily extracted in real-life domains.^4,5

As a more effective alternative to traditional pedagogy practices, Seely Brown et al. proffer cognitive apprenticeship. Concepts are introduced within the framework in which they are to be applied in the real world. As students master fundamentals, they then progress to more autonomous activity, all under the tutelage of a practitioner who uses these concepts in authentic domain activities. By using their basic understanding of concepts taught in real-world situations, their knowledge further evolves. Apprenticeship also organically leads to “enculturation” within a community of practice. Integral to a community of practice are social interaction, social constructs of knowledge, and collaborative. Cognitive apprenticeship can be applied broadly across multiple fields and is especially useful in disciplines involving higher-order human activities.

Modern takes on this Theory

Situated cognition theory has played a starring role in the evolution of modern medical education, particularly at the undergraduate level. The traditional model of reliance on didactics, written testing, and acquisition of factual knowledge that once defined medical school curricula, particularly in the 1st and 2nd (often called “preclinical”) years, has largely disappeared. Recognizing the need for a holistic educational framework, in which the student physician acquires knowledge not only from a textbook but within the dynamic clinical environment, educators have developed novel curricula that embrace the situated cognition theory. The following examples illustrate use of this theory in recent adaptations in medical education: 

Problem-based learning (PBL)⁶: A massive shift away from lecture halls to PBL has occurred recently in medical education and is a model example of situated cognition in practice. Students are provided with a case, initially simple and appropriate to the learners level, and are given more information as they progress through the case, in an attempt to provide quality care to the simulated “patient” This process is necessarily iterative; students must adapt and learn based on new and increasingly complex information from the hypothetical patient, context and clinical environment. Thus is the learning situational and acquired in the context of the patient-provider relationship. 

Preceptor-style clinical learning: The core of this theory is that education must take place in authentic environments, Preceptorships allow the student to learn from an expert in the chaotic and complex “real” patient care setting. Skills such as shared decision – making and delivery of bad news are as invaluable as they are impossible to learn outside of a situated and authentic setting. 

Patient-centered learning⁷: Patient-centered care focuses on patient participation, the relationship between the patient and the provider, and the context and accessibility of the care, and is now the gold standard for health care provision. medical education has necessarily become patient- centered as a result. Clinical exposure for students starting early in the first year and opportunities to follow patients longitudinally are novel applications of situated cognition, allowing the student to learn factual medical knowledge while concurrently understanding how the patient is affected by the disease within the larger sociocultural context. Additionally, there has been a recent emphasis in residency training programs on the use of patient feedback as an opportunity for reflection and improvement, again adopting the situated cognition theory that “book” knowledge is insufficient to learn excellent clinical care if the patient is unable to receive the care compassionately, sensitively, and professionally. 

Other Examples of Where this Theory Might Apply

Situated cognitive learning is occurring in clinical settings by a matter of course. The constant and complex interplay of the patient and the environment, the other staff and providers, as well as the experiences of the learner and educators, necessarily both affects the learning process and informs it. The inclusion of timely reflection and feedback is essential to learning in this environment as well, as the learner must be allowed to identify how and why the care of the patient changed as the interaction developed, and what he or she learned from that experience that will improve his or her future practice.  

In the classroom setting, simulations that allow for problem – based learning, in which information about the patient and the context are dynamic, are prime examples of the situated cognition theory at work. For example, emergency medicine fellowships in wilderness and global health use simulated case scenarios to teach fellows how to care for patients in low – resourced and austere settings. At this post – graduate level, the learner is highly educated in the field of emergency medicine but only in the context of the relatively highly-resourced western emergency department. For example: During a simulation, we may create a precipitous childbirth case with complicating shoulder dystocia – a condition the fellows should be able to manage. However, we add in a power outage and remove some equipment that would normally be available or place the scenario in a rural clinic with long transport times to a hospital. Such adaptations allow the fellow to learn in a dynamic and innovative fashion, in a scenario essential to the core competency of the fellowship. 

Limitations of this Theory

There are several limitations to practically adapting a situated cognition model in medical education. First, adaptation of traditional medical school structure to accommodate problem -based learning, longitudinal patient interactions, and early preceptorships – activities that embrace situated cognition theory – may be logistically and culturally difficult. Such a shift requires not only educators who are well – versed in these learning styles, but also a willingness to shift a well – worn and ingrained paradigm of medical education via lecturing, Socratic – style questions, and written tests. Moreover, placing learners in clinical situations or even high – tech simulation labs can be challenging depending on availability and cost of such resources. Such opportunities are also time – consuming, often requiring travel, and may be dependent on unreliable patient volumes. 

Another limitation is effectively evaluating learning interventions that use situated cognition: Without a traditional test or score sheet, the ability to measure acquisition of knowledge gained using situated cognition may be difficult and time – consuming. One must rely on direct observation, OSCE – style simulations, and qualitative data to evaluate within this theoretical context.

Returning to the case…

Faculty continued to discuss multiple residents’ performance and ultimately returned to the discussion of how to address perceived performance deficiencies. 

“In addition to individual plans for improvement, do we need to be looking at our curriculum and how our weekly conference is going?”

Since many of the faculty are also on the curriculum and conference committees, this discussion amplified and began to look systemically at the manner in which much of the programs leaning is being delivered.

“You know, several of us have been discussing the need for more integrated simulation and small group case discussions” one faculty remarked.  “We seem to be very heavy on delivered lectures without always making full connections to the clinical application of the knowledge.  I suspect that providing a more immersive experience may be beneficial for both learners like Paul and Peter.”

To further address the variety of learners within the program and in hopes to further engage faculty involvement in conference, program leadership looked to invoke principles related to situated cognition.  By increasing the use of clinical case discussions in conference, faculty and residents felt that the information was more relatable and applicable to clinical situations.  Additionally on shift, there was increased effort to relate clinical situations to common board-style questions that the learners will encounter.  

Through these changes, both learners and educators felt there was significant improvement in knowledge translation, both from conference topics to the clinical setting but also through utilizing clinical situations to cement the application of knowledge and allow it to be recalled based on the situational experience.

While it will take some time and additional evaluation to determine if these changes result in improvement across the board, both with clinical application of knowledge and translating that to knowledge recall in a standardized testing environment, initial indicators appear promising. By providing a learning experience drawing on situated cognition, Paul has improved his practice test scores significantly while on an improvement plan and Peter has been receiving significantly better on-shift evaluations and feedback.  

References

1. Artino Jr, Anthony R. It’s Not All in Your Head: Viewing Graduate Medical Education Through the Lens of Situated Cognition. Journal of Graduate Medical Education 2013: 5(2): 177-179.
2. Brown, J. S.; Collins, A.; Duguid, S. (1989). “Situated cognition and the culture of learning”. Educational Researcher. 18 (1): 32–42.
3. Hearn J, Dewji M, Stocker C, Simons G. Patient – centered medical education: A proposed definition. Medical Teacher 2019, 41(8):934-938.
4. Hall, Rogers. “Representation as shared activity: Situated cognition and Dewey’s cartography of experience.” The Journal of the Learning Sciences 5.3 (1996): 209-238.
5. Robbins, Philip, and Murat Aydede. “A short primer on situated cognition.” The Cambridge handbook of situated cognition (2009): 3-10.
6. Servant‐Miklos VF, Norman GR, Schmidt HG. A short intellectual history of problem‐based learning. The Wiley Handbook of Problem‐Based Learning. 2019 Apr 3:3-24.
7. Stewart M, Brown JB, Weston W, McWhinney IR, McWilliam CL, Freeman T. Patient-centered medicine: transforming the clinical method. CRC press; 2013 Dec 28.