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informal learning

Informal learning in postgraduate medical education:


from cognitivism to culturism
Tim Swanwick

Education is not simply a technical business of well


managed information processing, nor even simply
a matter of applying learning theories It is a
complex pursuit of fitting a culture to the needs of
its members and their ways of knowing to the needs
of the culture.1

BACKGROUND Work-based learning occupies a


central role in the training and ongoing development
of the medical workforce. With this arises the need to
understand the processes involved, particularly those
relating to informal learning. Approaches to informal
learning in postgraduate medical education have
tended to consider the mind as an independent
processor of information.
METHOD In this paper, such cognitive approaches
are critiqued and an alternative socio-cultural view on
informal learning described. Recent and imminent
changes in postgraduate medical education are
identified, namely the reduction in patient experience, the fragmentation of teaching, and the development of competency frameworks and structured
curricula. It is argued that although the latter may be
useful in the construction of formal learning programmes, they will do little to enhance the progression of the individual from newcomer to old-timer or
the cultural assimilation of the learner into a profession.
DISCUSSION Strategies for enhancing informal
learning in the workplace are recommended in
which increased attention is paid to the
Department of Postgraduate General Practice Education, London
Deanery, London, UK
Correspondence: Dr Tim Swanwick MA FRCGP, Director of Postgraduate
General Practice Education, Department of Postgraduate General
Practice Education, London Deanery, 20 Guilford Street, London
WC1N 1DZ, UK. Tel: 00 44 20 7692 3040;
E-mail: tswanwick@londondeanery.ac.uk

development of the medical apprentice within a


community of social practice. These include the
establishment of strong goals, the use of improvised
learning practices, attention to levels of individual
engagement and workplace affordances, immersion
in professional discourse and behaviours, support in
relation to the development of a professional identity and the provision of opportunities to transform
social practice.
KEYWORDS education, medical, undergraduate
*methods; curriculum *standards; students, medical *psychology; learning methods.
Medical Education 2005; 39: 859865
doi:10.1111/j.1365-2929.2005.02224.x

INTRODUCTION
Postgraduate medical education is predominantly
sited in the workplace. There are opportunities to
participate in structured tuition away from the
hospital or practice, but the bulk of learning is
expected to take place at, through or from work.
A number of bodies exist in order to facilitate,
enhance and quality-assure this process, including
Royal Colleges and Departments of Postgraduate
Medical Education. These organisations are also
responsible for ensuring that experienced doctors
participate meaningfully in a process of continuing professional development, a process which in
recent years has shifted from the clocking up of
time engaged in formal learning to a system
based on annual appraisal and the personal
development plan. Work-based learning has now
taken centre stage in the training and ongoing
development of the medical workforce and with
this has arisen the need to understand the
processes in operation, particularly those relating
to informal learning.

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informal learning

Overview
What is already known on this subject
Postgraduate medical education occurs predominantly in the workplace, largely through
an apprenticeship model. Informal learning
plays a central role in professional development.
What this study adds
Medical education has tended to emphasise
cognitive approaches to informal learning, but
learning can also be conceived as a cultural
phenomenon in which identity, knowing and
social membership entail one another.32
Recent changes in both service and education
require that, in the context of medical
apprenticeship, attention be paid to how the
socio-cultural progression of the individual
from newcomer to old-timer might be
enhanced.
Suggestions for further research
The impact of structured, competency-based
curricula should be carefully evaluated, particularly with respect to professional development.

INFORMAL LEARNING IN
POSTGRADUATE MEDICAL EDUCATION
Resnick2 defines formal learning as that which takes
place in an institution as a result of instruction, an
individual process, involving the purely mental activity of manipulating symbols resulting in the production of generalised concepts. Informal learning, by
contrast, is defined as characteristically collaborative,
usually involving the manipulation of tools and
leading to context-specific forms of knowledge and
skills. A distinction can also be made between formal
workplace learning and incidental learning.3 For
instance, Reber,4 adding empirical backing to
Polyanis concept of tacit knowledge,5 suggests the
term implicit learning as a descriptor for the
acquisition of knowledge independently of conscious
attempts to learn and in the absence of explicit
knowledge about what was learned.6

Informal learning, however, need not necessarily be


serendipitous and can be planned or emergent.7
Between these 2 extremes, Eraut8 proposes a third
category to describe situations where the learning
is explicit but takes place almost spontaneously in
response to recent, current or imminent situations
without any time being specifically set aside for it.
Eraut terms this unplanned but intentional learning reactive and places it in a tripartite typology
of informal learning between the implicit and
deliberative modalities discussed above. Informal
learning then is a complex and heterogeneous
concept, but is generally agreed to be central to
any form of learning that takes place predominantly at work.
In their approach to informal learning, postgraduate
medical educators have tended to adopt a cognitive
stance, viewing the development of the mind as
independent of its social context. Programmes for
educators9,10 and publications in the mainstream
medical literature1113 have focused on andragogy,14
experiential learning,15 and learning through reflection16 a process that may also be facilitated by
feedback. This emphasis on reflective and reflexive
(learning about ones learning) practice is further
highlighted by the wholesale adoption of appraisal
and the personal development plan as the future,
almost sole, vehicle for continuing medical professional development.1719
The second predominant focus in medical education
has been the traditional apprenticeship model,20,21
underpinned by the dual assumptions of learning by
doing and a master as a role model.22 The apprentice)master relationship is typified by the consultant
and junior on the hospital firm and the general
practice trainer)registrar dyad in primary care. The
modelling inherent in these relationships can be
described in terms of Banduras23 social learning
theory, in which observed behaviours, attitudes or
emotions are codified, reproduced and assessed by
the individual for value (valence) before being
adopted or rejected.
In all these formulations of adult learning, it can be
argued that information in is being inscribed,
sorted, stored, collated, retrieved and managed.1 In
Banduras case it is self-concept that is the object of
remodelling, whereas in the experiential and
reflective practice of Knowles, Kolb and Schon1416
it is the individuals worldview and his or her
interaction with it. In both instances, the mind is
assumed to be functioning independently of its
social context.

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Despite their widespread adoption, these ways of


thinking about learning often propounded as selfevident truths are roundly contested.
Andragogy has been criticised as being not a theory
of learning, but an educational ideology based on
insufficient research24 lacking universal applicability
as demonstrated by variations in self-directedness
and learner autonomy with class,25 culture26 and
maturity27 and rooted in a political belief of
knowledge as private and capital. Experiential learning has achieved sustained popularity in both education and management but, as Cheetham and
Chivers28 point out, the proposition that learning
from experience takes the form of a neat cycle as
suggested by both Kolb and Honey and Mumford is
also open to challenge. Learning seems likely to be a
more complicated and multifaceted process. Eraut29
sticks the knife in further: Although it features
prominently in the Kolb cycle, the notion that
learning from experience is a single type of learning
is patently absurd.
Modelling is also more complex than it first appears.
Bucher and Stelling30 identify 5 different types of
professional role model in their study of the acquisition of professional identity and others have suggested that what may be more important for learning
is for an adult to develop an idealised self-concept
and to progress towards that image.31 Furthermore,
role modelling in professional development has been
found to be less widespread than previously supposed28 and is not even ubiquitously characteristic of
apprentice learning.32
The cognitive approach of reflective practice and
modelling, in which a computational mind reframes
or reconstructs a worldview based on the processing
of inputs, is then probably not the whole story. In
apprenticeship-based education systems it also
becomes important to consider how that individual
mind develops within a society, and how it assimilates
with and contributes to that society through participation in, and transformation of, social practice.

CHANGES IN POSTGRADUATE MEDICAL


EDUCATION
A number of fundamental changes are affecting the
way postgraduate medical education will be delivered
in future. The UK Department of Healths publication Modernising Medical Careers33 calls for more
structured and organised training programmes

accompanied by timely, valid and reliable assessments


for all doctors in training. Various and varied pilot
programmes are underway across the country but the
future overall structure of both general practice and
specialist training remains unclear. What is clear,
however, is the intention to develop competencybased training programmes situated in the workplace
incorporating formal educative elements and workplace assessment.34 There is also sign-up to the
production of learning outcomes, curricula and the
development of skills and teaching and supervision.
At the same time, senior doctors are voicing concerns
about the lack of clinical experience obtained by
their juniors, a situation exacerbated by the constraints of the European Working Time Directive,35
which has reduced clinical commitment and,
through the implementation of shift systems, eroded
the professional relationships that previously existed
in hospital firms.
A third change is the increased sharing of training of
an individual both within and across institutions, but
also across disciplines. In both primary and secondary
care, increases in part-time working amongst trainees
and trainers is diluting the one-to-one master)apprentice relationship which has served the
profession well for many years.
It appears then that postgraduate medical education
will become more formal, more structured and more
distributed. It will also, in terms of the number of
hours served and therefore patients seen be
shorter. This may not be a problem if expertise
simply reflects the quality of skills-based training but
it is of concern if we believe Cornford and Athanasou,36 who suggest that The attainment of a level of
expertise in highly skilled professions will generally
not be attained before a minimum of 5 years in that
speciality and there is ample evidence that 10 years
may be typically the norm. These trends do, however, highlight the need to pay attention to the
processes by which a trainee develops into an expert
professional, and how these processes can be
enhanced.

SOCIO-CULTURAL APPROACHES TO
INFORMAL LEARNING
A number of authors have conceived learning as a
socio-cultural phenomenon. Bruners celebration of
culturism takes inspiration from the evolutionary fact
that the mind would not exist save for culture.1

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informal learning
Eraut8 presents 2 arguments as to why knowledge
may be conceived as a social, rather than an individual, attribute. The first of these hinges on the
concept of distributed cognition; that in certain situations individuals are unable to act effectively as they
depend on the knowledge of other people or other
things.37 The second argument is derived originally
from the developmental theories of Vygotsky38 and is
based on the concept that learning is embedded in a
particular set of social relations and that by inference
a given piece of knowledge may be socially rather
than individually constructed.
In their landmark study of Yucatec midwives, tailors,
quartermasters, butchers and non-drinking alcoholics, Lave and Wenger32 trace the progression of the
individual from newcomer to old-timer in which
legitimate peripheral participation in a community of
practice leads, in time, to full participation: Thus
identity, knowing, and social membership entail one
another.32 Lave and Wenger noted that very little
observable teaching took place in the 5 apprenticeships under study and that the foremost and more
fundamental educational process in action was
learning.
Lave and Wenger further noted that in an apprenticeship setting the curriculum unfolds with opportunities for engagement, and that engaging in
practice may well be a condition for learning.32
This theme of engagement as a fundamental prerequisite for informal learning is taken up by Billett,39
who places it as 1 of 2 foundational practices in a
workplace pedagogy. But it takes two to tango and
individual engagement is considered reciprocal to
what Billett defines as workplace affordances, that is
how the workplace invites and structures individuals
participation in work.39 This access to workplace
activities and guidance, he argues, shapes the quality
of learning and is socio-politically mediated, being
ultimately premised on the workplaces participatory
practices, so that the workplace confirms whether the
individual is to be considered as a learner and defines
the educational opportunities to be provided as a
result.

ENHANCING INFORMAL LEARNING IN


THE WORKPLACE
Thus there is a subtle process of change at work as a
trainee develops into a professional, a process which
itself is more about being than doing, and this
progression may be enhanced by creating a favour-

able working environment. Again, in their


consideration of environment, medical educators
have tended to concentrate on facilitating cognitive
processes, by, for instance, the creation of reflective
time and opportunities for modelling. In shifting
the focus to the socio-cultural, what then are the
implications for the design of professional development programmes in postgraduate medical education?
Strong goals
Without well determined goals, it may be difficult for
the newcomer to establish a developmental direction;
even those who espouse complexity as a metaphor for
interpreting education40 recognise the need for
leadership and the organisation of chaos.41 Without
some order, engagement, confidence and the commitment of learners will be affected. It becomes
difficult to identify the community of practice and
workplace affordances may suffer. In essence, a lack
of strong goals will erode all of the other factors listed
below.
In a long-established social practice such as medicine,
goals are usually traditionally and explicitly defined:
to become, for instance, a neurosurgeon or a doctor.
However, the downside of this is that they tend to be
relatively invariant and professions, and their curricula, are slow to adapt to changes in social practice.
Improvised learning practices
The appropriate units for adult learning are situations, not subjects, and whereas this statement has
andragogical echoes, the transition from peripheral
to full participant must also be contingent on the
handling of situations as and when they arise. The
role of the educationalist then becomes that of
structuring experiences rather than transmitting
knowledge.
Eraut42 found 5 types of work activity that regularly
gave rise to learning:

participation in group activities;


working alongside others;
tackling challenging tasks;
problem solving, and
working with clients.

All of these facilitate a process of acquisition rather


than transmission and the educationalist is tasked
with ensuring access to these experiences. An anal-

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ogous list of non-linear methods borne out of the


application of complexity theory can be found in
Fraser and Greenhalgh.41 Examples in postgraduate
medicine might include: collaborating in an audit
project with colleagues; assisting at an operation;
performing a home visit out-of-hours; being asked to
develop a holiday rota for the firm, and managing an
individuals palliative care.
Individual engagement
Without individual engagement learning will be at
best strategic or superficial,43 and at worst, nonexistent, and engagement is contingent on the
relatedness of the individuals interests and values
with those of the social practice: The greater this
relatedness, the greater the likelihood of full-bodied
and committed participation.39 It becomes important then to match individual attributes with the social
practice with which they are expected to engage. The
centrality of engaging with the trainees mission is
well described in the general practice context by
Neighbour.44
Workplace affordances
The workplace is responsible for shaping both
unintentional and intentional learning activities
through its participatory practices. Workplace affordances will vary from site to site and from social
group to social group and educational managers
need to examine institutional arrangements and
workplace norms to establish the degree to which
these are invitational or excluding.
Fuller and Unwin, in their study of the modern
apprenticeship scheme,45 found that workplaces
operating successful schemes exhibited a number of
characteristics. Some of these related to the configuration of formal and informal learning, but others
were illustrative of workplace affordances in that they
allowed for participation in multiple communities of
practice, the development of a participative memory
within the primary community of practice and the
provision of a breadth of access to learning opportunities. The enhanced or, in Fuller and Unwins
terminology, expansive apprenticeship model also
exhibited a number of affordant institutional features, including the explicit recognition in the
employment relationship of the apprentices status as
learner thereby legitimising the learners peripheral participation and a highly developed reification
of the apprenticeship, connected with practice and
accessible to all apprentices. Fuller and Unwin argue
commonsensically, although with little hard evidence

to support the view, that organisations which offer an


expansive approach to apprenticeship are more likely
to create learning opportunities that foster deep
learning.45 (p 9)
Applied to medical education, the concept of an
expansive apprenticeship supports the idea of teaching units (teams, hospital or practices) providing a
broad base of experience both within and outside the
immediate working environment. The explicit
recognition of the doctor as learner, rather than
service provider, is also key, as is the reification or
codification of materials associated with that attachment, in the form of manuals, logbooks and learning
materials.
Professional discourse and behaviours
Social constructivism posits that knowledge resides
within cultures and that social meanings are shaped
through communication with others.46 Our worldview is constructed from the stories we tell and
conversations we have about it. The language we use
as professionals defines how we think and feel. As
Bourdieu argues, Even the simplest linguistic
exchange brings into play a complex and ramifying
web of historical power relations between the speaker, endowed with a specific social authority, and an
audience.47 Doctors have a particular position in
society, accompanied by a specific set of power
relationships in relation to both their patients and
colleagues. Appropriate socio-linguistic acquisition in
medicine then becomes a particularly important
issue.
As far as discourse is concerned, the task of the
newcomer is not to learn from talk, but to learn to talk.
Learning to talk the talk ) adopting the symbolic
representational systems of the group ) and walk the
walk ) taking up professional behaviours and utilising professional artefacts ) are important staging
posts on the road to full participation. The appropriation of relevant symbolic systems by the learner is
dependent not only on knowledge acquisition from
formal sources ) books, lectures and so on ) but also
on social interaction with more knowledgeable
members of that society. This is a process that may be
enhanced by, for instance, story-telling48 and threatened by the deployment of non-medical educators
and skills laboratories.
Professional identity
As the newcomer develops, the value of his or her
contributions to social practice increase the trainee

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informal learning
surgeon progresses from performing simple
appendectomies to complex bowel resections. The
practitioners sense of identity as a master is
enhanced as he or she offers graded contributions,
from low to high accountability, and through being
presented with work opportunities of increasing
challenge and value42 the individual develops a
heightened sense of professional identity. Central to
this escalatory process, however, must lie feedback
and support, and the building and maintenance of
learner confidence.49 High self-esteem is essential for
learning.31,42
Opportunities to transform social practice
Increasing participation in social practice results not
just in knowledge acquisition but also in knowledge
production and this too is an essential part of
developing a professional identity.22 All learners
should have the opportunity to mould social practice
and develop new ideas. In medicine this might
include devising a patient recall system or carrying
out a PDSA (plan-do-study-act) cycle to improve some
aspect of health care provision. Bleakley50 illustrates
this point well in his discussion of ward-based
transformative learning in pre-registration house
officers.

dimension of informal learning have been presented


and these should be considered in the design of
future educational programmes.
Medical education is subject to ever-increasing managerialism fuelled by an inexorable drive for
increased public accountability. Competency frameworks and externally imposed topic-based curricula,
although explicit and arguably useful in the construction of formal learning programmes, will do
little to enhance the socio-cultural progression of the
individual from newcomer to old-timer. In restructuring medical education we must ensure that the
processes facilitating the progression of the medical
apprentice are not lost least, as Gamble52 cautions,
apprenticeship becomes a sociologically and pedagogically empty practice, divorced from its original
social function and purpose as a transmitter of
identity based on mastery.

Acknowledgements: none.
Funding: none.
Conflicts of interest: none.
Ethical approval: not applicable.

REFERENCES
Transforming social practice, then, not only legitimises the learners participation, but also shapes the
very community of practice into which the learner is
being absorbed. The workplace in turn benefits from
becoming knowledge-producing, a noted feature of
successful organisations.51

2
3
4

CONCLUSION

Informal learning has been identified as a major


component of postgraduate medical education.
Where informal processes have been explicitly considered there has tended to be an emphasis on
cognitive models of reflection on experience and
modelling. Socio-cultural theories founded on the
work of Vygotsky,38 and later developed by Lave and
Wenger,32 offer a different perspective, shifting the
focus to how the mind develops within its cultural
setting. By paying attention to the learning climate,
the process of assimilation of an individual into a
particular culture may be enhanced.
In the wholesale redesign of medical curricula there
is the danger of fragmentation, reduction in practical
experience and a loss of access to social practices.
Several factors that may enhance the socio-cultural

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Received 28 May 2004; editorial comments to author 10


August 2004; accepted for publication 19 August 2004

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