Review Article

Adult learning theories

and medical education: a review

Jürgen Abela

Abstract Introduction
Adult learning theories describe ways in which adults In the past, there has been an assumption that if a person
assimilate knowledge, skills and attitudes. One popular theory knows very well the subject, then, he will be able to teach it.
is andragogy. This is analysed in detail in this review. The However the complexity involved in practising medicine must
importance of extrinsic motivation and reflective practice in be tackled with appropriate educational strategies in the training
adult learning is highlighted, particularly since andragogy fails and education of undergraduate and postgraduate students. In
to address adequately these issues. Transformative Learning fact, training teachers in educational techniques translates in
is put forward as an alternative concept. Using the three better student learning outcomes.1
recognised domains of knowledge, skills and attitudes, ways of The aim of this review is to present and analyse andragogy in
applying these theoretical concepts in medical education are the broader context of adult learning theories. Ways on how to
subsequently discussed. apply educational theories will be put forward, with the ultimate
aim being to foster medical competence.

Adult learning theories

Given that in the medical context most education involves
adults, it is logical to focus on adult learning theories. There are
many adult learning theories, which can be grouped into five
main classes. These include Instrumental learning, self-directed
learning, experiential learning, perspective transformation and
situated cognition.2 Of these, self-directed learning particularly
focuses on the individual learner as primary focus. Prominent
amongst these self-directed theories is andragogy.
The term andragogy (andra – meaning “man”; agogos
– meaning “learning”) was first used by Alexander Kapp in 1833
to describe the educational theory of the Greek philosopher
Plato. He used it to refer to the normal process by which adults
engage in continuing education. In the 20th century, various
respected intellectuals, such as John Dewey, Eduard Lindeman,
and Martha Anderson pursued theories of andragogy, but were
largely ignored in the US. Things changes in the 1980’s, with
the work of Malcolm Knowles who championed this theory and
Keywords further elaborated the concept.3
Adult learning, medical education, reflective practice
Andragogy assumes that adults:
• are independent and self directing,
• have (various degrees of) experience
• integrate learning to the demand of their everyday life
Jürgen Abela MSc, MRCGP • are more interested in immediate problem centred
Department of Primary Health Care, Floriana approaches and
[email protected]
• are motivated more by internal than external drives.

Malta Medical Journal Volume 21 Issue 01 March 2009 11

 Another characteristic deemed to be relevant to adult
Figure 1: Maslow’s Hierarchy of Needs
learning environments, is the importance of mutual respect
which drive motivation
between teacher and learner and also amongst the learners
themselves. Respect is important since it is a catalyst for a safe
educational environment.4
Self
Unfortunately, reflection is left out of Knowles’ concept of
Actual-
adult learning, despite being an important component of adult
isation
learning skills.5,6 In fact, reflection is the second of the four
steps in Kolb’s Learning Cycle.7 In addition, the importance of Esteem Needs
reflection can be appreciated even more when one considers it to Self-esteem,
recognition, status
be an important difference between adult learning (andragogy)
and child learning (pedagogy) theories. Finally, reflection can Social Needs
Sense of belonging, Love
be seen to enhance adult learning by increasing motivation to
learn.8 Safety Needs
Motivation is another important pillar on which adult Security, Protection
learning is built. There are two major groups of theories
Physiological Needs
describing motivation: Hunger, Thirst
• content theories: these describe what motivates people,
and
• process theories: these describe how people are
motivated.9
In andragogy, Knowles states that adult learners are
One of the most popular of the content theories is Maslow’s self (intrinsically) motivated.3 He fails to mention extrinsic
Hierarchy of Needs.10 The hierarchy moves from the most basic motivation and especially, the role of the teacher as major
needs, such as physical needs and security culminating in self- source of motivation. In fact, as Peyton9 points out, most adult
realization (Figure 1). The importance of a safe educational learners require the motivation provided by teachers for effective
environment cannot be overstated in the successful progression learning to take place.
of the learner through the hierarchy of needs as described by Not all adult learners are equally intrinsically motivated,
Maslow. Thus the importance of respect as stated previously. and this further highlights the inadequacy of andragogy with
However, Maslow’s model may be seen to be too rigid. In respect to motivation. In fact, there necessarily arises the need
addition, an individual may be satisfied and unsatisfied with of a mix of learning strategies, ranging from teacher-directed
various needs simultaneously throughout his learning trajectory. to student-directed learning.13 This implies that there needs to
It can thus be seen to be inadequate. A more appealing content be a “match” (Figure 2) between the learner and the teaching
theory is the one put forward by Clayton Alderfer, who describes styles used.14
and summarises motivation in three needs, ERG:9 But how does one strike a “match” between learner stage
• Existence – this is more or less equivalent to Maslow’s and teacher style?
safety and physical well being steps Certainly, this involves an amount of flexibility on the part
• Relatedness – stresses the importance of interpersonal of the teacher. The most important step to clinch such dynamic
and social relationships relationship is to carry out a needs-assessment of the student/
• Growth – intrinsic individual desire for personal growth trainees involved. Without such needs assessment, teaching
would be tantamount to treatment without a diagnosis. For
Process theories of motivation, on the other hand, are based example, whereas in the first clinical attachments, students
on the idea that certain behaviours are produced by particular would be dependent on the teacher to show them how to take
stimuli. One such theory is the Expectancy Theory which states a history, during the subsequent years, the learning strategies
that motivation depends on two perceptions:11 should deal with examination skills, going on further along the
1. an expectation that an outcome will bring the desired months to discussing the differential diagnosis and treatment
rewards of the patient’s symptoms. This shift in teaching stages will
2. the required performance is within the capability of the hopefully be matched by the progression of the learning stages
person.

12 Malta Medical Journal Volume 21 Issue 01 March 2009

 Figure 2: Matching learner stages to style14

Teacher Styles
Key: Authority, Salesperson,
expert motivator Facilitator Delegator
Match Dependent
Learner Match
Learner Stages

Near Match
Interested
Learner Match
Mismatch
Involved
Match
Severe Mismatch Learner

Self-directed
Learner Match

coupled with the learner getting more involved (motivated) in of the teacher in facilitating learners to question and reflect
the process. This dynamic process can be successfully achieved on their own and others’ assumptions.12 Methods that may be
with a variety of tools: particularly useful in this situation include critical incident
• Reflective diary/practice – this will stimulate reflection analysis, small group work to formulate ideas on particular
and facilitate in-depth search on certain topics in addition topics and reflective practice.
to allowing for personal development. Transformative learning is still in its development, and
• The relevance of what is being taught to medical practice certainly there is the need of more research along this line.15
should always act as a background for any discussion on It is very similar to and indeed complements the idea of The
topics. Inner Apprentice.16 This concept was put forward by Neighbour
• Use of the trainees’ experiences to discuss issues in in 1992, to describe the learning process of trainees. Neighbour
practice, especially at postgraduate level. put forward this concept to highlight what he called The Inner
• Small group work on abstract or “difficult” concepts e.g. Apprentice i.e. the unconscious learning mechanism that is
end of life. intrinsically self-educating, provided the right information is
• Problem based learning. provided in the right place and at the right time. Given such
• Open discussions on “hot topics” such as medico-legal favourable learning climate, the inner apprentice (trainee)
litigation. acquires knowledge (learns) by moving from cognitive dissonance
to cognitive resonance through stages of “kairos.” Kairos in
Given that andragogy fails to adequately address reflection Greek means the right time of action, and by analogy, during
and motivation, Mezirow’s concept of Transformative Learning points of “kairos” the trainee can most clearly recognise the nub
seems more appropriate. Crucial to this theory are the structures
12
of the issue and is most receptive to mutative information. This
and mechanisms through which adults assimilate and understand mutative information eventually leads to changes in the frames
their experiences. Transformative learning aims to effect change of reference to achieve cognitive resonance.
in established reference points used by the adult learner. These so Going through the theories of adult learning, one runs
called frames of reference are the meaning which people give to the risk of losing track of what they stand for – to enhance
experiences and the structures used to arrive to such meaning. It adult learning and facilitate effective teaching. In other words,
is thus clear that these frames of reference are a reflection of the in the medical field, this means the achievement of medical
genetic make-up and cultural assimilation of the particular adult. competence, whatever speciality, by the trainee. Indeed,
These frames of reference can be transformed through a variety achieving medical competence should be (and usually is) one
of ways, but primarily can be changed by critically reflecting on of the ultimate motivations of any medical educational setup.
the assumptions which make up each frame of reference. This statement is many times taken for granted, but medical
In line with the motivating role of the teacher in adult education, may at times actually lead to incompetence.17 Medical
learning, Transformative Learning stresses the importance competence can be defined as:

Malta Medical Journal Volume 21 Issue 01 March 2009 13

 “The habitual and judicious use of communication, divided into four distinct areas. These divisions allows for easier
knowledge, technical skills, clinical reasoning, emotions, values understanding and management of knowledge (Figure 3).
and reflection in daily practice for the benefit of the individual Through this categorisation, various aspects of knowledge
and the community being served.”18 can be addressed accordingly, though area 4 (The Unknown
Medical education, including its theoretical basis, should area) is not amenable to modification. Thus area 2, is called
effectively address all of these issues to produce competent the Blind Spot since it refers to knowledge not known to the
trainees. This implies that there needs to be a sound and effective trainee. This can be addressed through didactic-interactive
application in practice of theoretical concepts, using the fact type lecturing, where new information is provided. Area 3 is
that medical education is based on three interrelated domains, called the Facade Area, and refers to what the person knows
which are knowledge, skills and attitudes.19 Knowledge can be about himself which the rest of the people do not know. This can
defined as: be tackled using discussions and small group work. Teaching
“…a background of facts and interactions between facts of both areas 2 and 3, and possibly area 4 is augmented with
that should lead to an understanding of the material being reflective practice.
learned”20 Skills are very much the panacea of medical institutions.
Lack of knowledge is occasionally difficult to identify. An Until recently the adage used to be “see one, do one, teach
interesting way to picture knowledge (and the lack of it) in one.” This method fosters a sense of competition and pride
learners is by the using the concept of JoHari Windows (JW) in the medical profession but at the same time creates undue
put forward by Joseph Luft and Harry Ingham (hence: Joseph & tension in the learner and also may inhibit exploration of various
Harry = JoHari) . They developed this model in the 1950’s while
21
aspects of the studied skill for example when things go wrongs or
working on group dynamics. The JW can help to illustrate and possible complications which arise during or after the particular
improve the self-awareness between individuals and teams. It is procedure. In addition, certain skills such as communication
sometimes called a disclosure/feedback model of self awareness. skills do not lend themselves readily to this format.
The applications of this model are many, and one particularly A practical example in the case of surgery would be
good use of it is to map out the trainee’s knowledge, which is teaching a trainee how to remove a sebaceous cyst. The

Figure 3: The Johari Window21

14 Malta Medical Journal Volume 21 Issue 01 March 2009

practical skill involves setting the scene correctly, using a On the other hand, surgical based specialties, will be more
sterile environment, preparing the skin, using the necessary prone to pass on practical and hands on attitudes. These two
instruments appropriately, removing the cyst with the capsule, examples highlight the importance of exposing undergraduates
suturing the wound ending by submitting the sample for to a mix of specialties, away from the traditional setup, to aid
histological assessment. However, in addition, to this, it is the development of appropriate attitudes.
important to discuss the complications and their management, Another relevant way of passing on appropriate attitudes is
besides stressing the importance of providing proper information teaching in the clinical environment (also known as On the Job
to enable the patient to make an informed consent. Teaching - OTJT). Together with providing an opportunity to
George & Doto offer an interesting skill-teaching pass on skills and even knowledge, OTJT offers an opportunity
framework:22 to discuss, albeit briefly, various issues which may crop up from
1. Overview: introduction to why the skill is needed and different clinical scenarios.26 Such issues may include ethical
its relevance in the area of practice of the learner. Basic questions and dealing with one’s own feelings when faced with
concepts on the skill. a sick patient. Certainly, a traditional lecture will not be able to
2. Demonstration without comment: allows the flag up these attitudinal challenges.
learner to observe a whole picture of required skill. For a successful OTJT experience, planning and commitment
3. Demonstration with comment: allows fragmentation on behalf of the teacher is paramount. In addition, time pressures
of the skill into more manageable portions. will certainly make things more difficult for teaching, especially
4. Verbalisation: learner talks through the skill. during a busy ward round or outpatient session. However, the
5. Practice: the learner executes the skill. trainees will have the opportunity of seeing the teacher interact
with the patient, and also with adequate planning there can be
In addition, it is felt that the final stage can be further room for small discussions. There are various methodologies
supplemented by positive feedback and encouragement from of carrying out OTJT which have been highlighted in a recent
the trainer. systematic review and are summarised in Table 1.27
George & Doto go further and describe reasons which may Feedback, in such situations and indeed in all situations
prevent the acquisition of the required skill such as inadequate should be given along Pendleton’s’ rules, thereby not
demonstration/description, imprinting of previous wrong undermining the standing of the student or trainee.28 By being
exposures and improper correction. These have to be kept in allowed time and space to explore one’s own thoughts, the
mind when teaching a skill. frames of reference (as outlined in Transformative Learning)
The last domain in medical education is attitudes. In related to attitudes can be changed and modelled accordingly.
guidelines of desired medical conduct the attitudes of the
medical professional are highly regarded.23 However, it is Conclusion
generally felt that in medical curricula this aspect is not given Addressing all of the above issues in a systematic way can
its due recognition. Through their own nature, attitudes are be an arduous task, even for the most dedicated of trainers!
difficult to describe, quantify and address. Passing on desirable However, the educational cycle is a useful concept for planning
attitudes seems even more difficult. teaching activities. It consists of four steps:7
Attitudes can be defined as “…a learned predisposition to 1. Assessing the needs of the learner
respond in a consistently favourable or unfavourable manner 2. Setting educational objectives
with respect to a given object.”19 3. Choosing and using a variety of methods
There are various ways in which attitudes can be addressed. 4. Assessing that learning occurred.
In the undergraduate scenario, certain specialties, more than
others, are useful in passing on particular attitudes. General In conclusion, andragogy is a popular theory used in medical
practice and palliative care, for example, through their educational. However, adult learning goes beyond that described
philosophies of holistic assessment and “total care” respectively, by andragogy. Indeed reflection and (extrinsic) motivation
are suitable to pass on attitudes related to managing the patient are insufficiently addressed by this concept. Transformative
and family. 24,25
Learning, though in its infant stages, seems to be particularly
In fact, “incorporating palliative care into medical appealing since reflection is given prominence. There needs to be
training not only improves the quality of palliative care, but more awareness of the role of the teacher in acting as a catalyst
also contributes to the moral quality of the doctors being for motivation. In addition, less traditional methods of teaching,
trained.”19
including small group work and reflective practice should be

Malta Medical Journal Volume 21 Issue 01 March 2009 15

 Table 1: Types of ambulatory teaching methods

Assess learner before clinical encounters, orient to the clinical site and preceptor
1. Orienting learner
style and expectations
2. Prioritising learning needs Before clerkship/clinic session, assess, prioritise, and tailor learner’s experience.
3. Problem-orientated Focus on a theme for clinic day to control variability inherent in office-based practice
learning (e.g., well-child visits).
Teacher-directed brief (1–2 minutes) orientation of learner to the patient and task(s)
4. Priming
immediately before entering the patient’s room.
The “Aunt Minnie” method emphasising learner report of chief complaint and
5. Pattern recognition
presumptive diagnosis rather than detailed case presentation.
6. Teaching in the patient’s Learners present findings in front of patient with preceptor “teaching” in response to
presence this presentation
7. Limiting teaching points Focus on 1 to 2 key concepts/principles per teaching interaction.

8. Reflective modeling Learner observes preceptor actions complimented by preceptor explanations.

Allows preceptor to assess learner to guide subsequent teaching of higher/lower-
9. Questioning
order concepts.
Ongoing provision of information designed to guide learners’ performance beginning
10. Feedback with concrete experience, learner self-assessment, abstraction of experience to
general concept, then testing validity of concept (Kolb).

11. Teacher/learner reflection Connects new elements to existing knowledge for both learner and teacher

encouraged. Any learning activity, should ideally address the 9. Morrison R. Motivation in Teaching and Learning. In: Peyton
J, editor. Teaching and Learning in Medical Practice. First ed.
knowledge, skills and attitudes necessary to become competent
Guildford: Manticore Europe Limited; 1998. p. 41-57.
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achieving such aim. The educational cycle is simple and useful Row; 1970.
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to plan activities. 12. Mezirow J. Transformative Learning: Theory to Practice. New
directions in adult and continuing education. 1997;74:5-12.
13. Merriam SB. Andragogy and Self-Directed Learning: Pillars
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