Educating doctors in the clinical workplace: Unraveling the process of teaching and learning in the medical resident as teacherJO Busari1, AER Arnold2
1 Department of Pediatrics, Atrium Medical Center, Henri Dunantstraat 5,6401 CX Heerlen, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, University of Maastricht, POB 616,6200 MD, Maastricht, Netherlands
2 Department of Cardiology, Medical Centrum Alkmaar, Wilhelminalaan 12,1815 JD, Alkmaar, Institute for Medical Education, Free University Medical Center, Van der Boechorststraat 7,1081 BT, Amsterdam, Netherlands
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.58935
Source of Support: None, Conflict of Interest: None
In recent years, higher medical education has witnessed major changes in the structure and content of postgraduate medical training. Seven professional competencies have been described that address the medical doctors' ability to effectively communicate and transfer medical information, interact effectively and professionally, and demonstrate a good grasp of clinical knowledge and skills. Proficiency in didactic skills, however, is an important competency that has not received prominent attention. In the clinical setting, attending-physicians and medical residents are responsible for teaching. Consequently, several medical institutions have proposed the need for teacher training programs to improve the teaching skills of attending doctors and medical residents. The supporters of these programs believe that through teaching, medical doctors improve their individual professional and clinical problem-solving abilities. Hence, it is logical to assume that didactic skills' training would contribute to the professional development of doctors. In this paper, we re-examine the underlying theory of the didactic proficiency, how it relates to the clinical setting, and why it may be beneficial for the professional training of medical residents.
Keywords: Didactic skills, educational theory, knowledge, medical residents, teaching
In the last couple of years, higher medical education has witnessed major changes in the development and assessment of postgraduate medical training. Competency-based training has emerged from this process as one of the most notable changes, where the progress of professional development is defined solely by the trainees' achieved competencies and not by the underlying processes (or time served) in formal educational settings. This new approach is characterized by a functional description of the occupational roles of the physician, the translation of these roles into outcomes, and the assessment of trainees' progress based on the demonstrated performance of these roles. 
In several countries in Europe and North America, different professional roles have been used by medical institutions to describe these desired competencies. For example, Canada and the Netherlands use seven professional roles to describe the desired competencies of physicians after their training while the United States uses six. Although these roles differ slightly in content and number, the scope of the competencies described remains essentially the same. ,, In this new competency-based form of training, the possession of effective didactic skills has also been highlighted as an important competency for physicians. The revised CANMEDS curriculum, for example, demonstrates the need for good teaching abilities in the role as "scholar" while the ACGME reflects the importance of teaching in the "practice-based learning and improvement" role. ,, Since attending doctors are mainly responsible for teaching in the clinical workplace and medical residents (MRs) also contribute to this process (i.e. 70% of what students learn) , it is essential that there is an opportunity for them to continually improve their didactic skills ,, as the process of teaching can also improve their professional and clinical problem-solving skills. , We shall be re-examining the underlying theory of didactic proficiency in this paper and demonstrate how it can be helpful for MRs as clinical teachers.
An important function of the educational process is to provide learners with the necessary materials and experiences that facilitate individual learning. The required conditions for this process include: a) the knowledge of how to teach (didactic knowledge) b) the general principles of education and c) proficiency in domain-specific knowledge.
Research conducted on how expert clinicians apply their knowledge in clinical practice shows that they regularly make use of compiled (encapsulated) knowledge in their thought processes.  These compiled forms of knowledge i.e. "Illness scripts" are clinical scenarios associated with mental problem-solving strategies. Expert physicians apply these illness scripts in teaching and solving clinical problems or dilemma. Generated after (previous) patient encounters, illness scripts are committed to memory and are retrieved when physicians are faced with similar clinical problems in new patients. The moment a patient's problem fails to match the stored illness scripts, however, expert clinical teachers switch to the conventional method of analytic reasoning to solve the problem. For the MRs who are relative novices and possess a sparse store of illness scripts, networks between the different forms of knowledge need to be developed through analytic reasoning. The experiences, contexts and problem-solving strategies associated with these knowledge networks are subsequently stored as illness scripts that experts utilise in clinical practice.
Research on the information processing system of the human mind has shown that memory is not a whole piece, but comprises several major subsystems. , Aspects of the organization of these subsystems can be anticipated by understanding the ways in which memory contributes to various cognitive activities and the constraints under which it operates. The most basic constraint is that mental processes take time and are very slow when compared for example, to the operation of a computer. A second constraint is that for the information in memory to be useful, it must be organized for retrieval. The process of sifting, classifying and entering information into memory in a way that makes recovery reasonably efficient over time is referred to as knowledge acquisition [Figure 1].
According to Klausmeier, concept attainment occurs at four stages of learning, namely concrete, identity, classificatory and formal levels.  The first stage of understanding involves discriminating an item as an entity from its surrounding i.e. concrete level. The ability to later recognize the item as the same entity when it is either in the same or different spatial orientation (or context) is referred to as the identity level. Generalizing two or more examples of a concept as equivalent is the classificatory level and being able to apply the concept(s) in understanding a topic and/or solving a problem is the formal level. This formal level completes the process of learning (or conceptualization). For example, the ability to distinguish muscle from other structures in the body and knowing that it is made up of myofibrils containing the thick (myosin) and thin (actin) filaments that are responsible for contraction constitutes a concrete level of understanding. When the learner understands for example that different structures (organs) in the body e.g. biceps, triceps, bladder, heart, stomach and intestine can contract and do so because they contain muscle and the filaments actin and myosin, then there is an identity level of understanding. Subsequently, being able to classify biceps and triceps muscle as belonging to the same class of muscles based on their anatomical structure and location in the body (striated/skeletal muscle) reflects a classificatory level of understanding. Finally, applying this knowledge to solve a problem of why an individual cannot move his limbs e.g. is it a primary muscle, skeletal or combined problem, demonstrates a formal level of understanding.
When knowledge is attained by the learner after the formal level of understanding, it is usually categorized into different conceptual forms i.e. domain-specific, general and strategic knowledge. Domain-specific knowledge refers to information about a specific topic to be learnt, or task to be performed. In the case of the muscle unit, we can refer to the domain of skeletal muscle and the physiology of limb movement. General knowledge is knowledge that is not directly related to understanding the task to be performed, however essential for the completion of the task, for example knowing that limb movement occurs due to the interaction between the musculoskeletal and neuromuscular pathway and that the knowledge of this process is important for solving problems related to impaired limb movement. Finally, strategic knowledge is knowledge about the manner in which tasks are completed. It involves the skills of combining the two prior forms of knowledge in such a way as to produce a product satisfactory for the learner and other potential audiences.  In order to facilitate effective learning in students, the different forms of knowledge should be applied appropriately. This is because their application in their learning environment (singly or in combination) determines how easily the concept to be learnt is transferred and acquired [Box 1].  [Additional file 1]
There are several theories in the literature that explain the process of knowledge acquisition and compilation. However, the general consensus is that knowledge has to be bundled and packaged in such a way that the learner can easily retrieve and apply it when solving problems. ,,,, The Neves and Anderson's theory of knowledge compilation illustrates this point in its description of the operational process.  It shows that knowledge is compiled in three steps; first by committing a set of facts to memory (Encoding), turning the facts into procedures (Proceduralization), and improving the pace and performance of procedures through practice (Composition).
To begin with, all knowledge is encoded as a set of facts within a network and is referred to as declarative knowledge. This declarative knowledge requires time to be interpreted and subsequently turned into action. So long as this knowledge is stored and not processed, it contributes to the memory load of the learner. However, as soon as it is interpreted and activated, it is utilized and transformed into procedures. The knowledge then becomes procedural knowledge that can be directly executed and requires no more interpretation. At this stage of proceduralization, knowledge becomes implicit in the learner's action, and the memory load diminishes. Having acquired the procedural knowledge, the actions that originate from the learner have to be integrated and combined to be of value. This combination process is referred to as composition and is characterized by organizing the learnt procedures into integrated sequences [Box 2]-[Additional file 2] .
The setting into operation of the newly attained procedural knowledge and the performance of new tasks completes the process of learning. At this stage of knowledge application the newly learnt knowledge or skill is put into use to perform specific tasks or procedures. This stage also initiates the phase of lifelong learning and mastery of skills as represented in the process of deliberate practice. 
The implication of the process described above is that the performance on any cognitive activity will be awkward and slow in the beginning as the knowledge has not entered the phase of proceduralization i.e. implicit knowledge being put into action. It explains why learners may sometimes appear clumsy or hesitant when learning new skills or concepts. When learning proceeds, the knowledge of facts transforms into knowledge of how to use facts (i.e. procedural knowledge) which is more readily available for use. The subsequent compilation of the available proceduralized knowledge, integrating and (re-)combining it, results into efficient mental (and procedural) tasks over time. As a result, performance that appears halting initially improves later, into a reasonable level of competency [Box 3]-[Additional file 3] .
The theory of didactic proficiency
During their professional training, MRs are (often) expected to teach and supervise medical students and peers despite little or no prior training in teaching. The assumption is that this task is an inherent aspect of their professional training, which they should be competent in at the end of their program. It is argued in the literature that by teaching MRs the fundamental theories of education, their individual learning as well as the way they relate to medical students when teaching would improve. MRs would gain a better understanding of how they learn and improve their individual learning skills in the process. , They would understand as learners, how the process of knowledge acquisition, compilation and transfer takes place and develop the necessary cognitive skills to apply them in practice. As teachers, they would learn to relate to medical students differently and improve their teaching abilities by applying their understanding of knowledge acquisition and transfer to facilitate the process.  It is this bridge between the principles of teaching and the skills required to translate it into practice that underlie the theory of didactic proficiency.
The clinical learning cycle
The clinical learning cycle in [Figure 1] provides a schematic illustration of the different stages involved in this process. It shows that learning is a dynamic process that involves the application of basic learning principles in the performance of new tasks. This cycle also includes the process of (self)-reflection, best described by Kolb's experiential learning theory. While the theoretical model of didactic proficiency highlights the essential steps involved in the process of learning, the Kolb's experiential learning cycle helps the learner to evaluate, restructure and re-formulate learning goals based on the output from the learning process [Figure 2].  By integrating the cognitive and socio-emotional factors that influence learning with one another, self-reflection closes the entire educational activity with the evaluation of the educational process itself and the reformulation of new learning strategies for, and by the learner.
Approach to learning
In addition to the cycle of learning, the approach to learning is another important concept in the theory of didactic proficiency. The approach to learning is the relationship between the content of what learners (are expected) to learn, the learners themselves and the ability of clinical teachers to recognize this relationship in the educational setting. There are two separate domains that describe this concept, the first being whether or not the learner is engaged with the learning task (deep approach) as opposed to just searching for meaning (surface approach) and the second being the differences in how the learner organizes information, and whether the framework of a task is distorted or segmented.  When an expert's argument is confused with the evidence used to support it, and each component is seen as a single sequence of "facts" then the approach is atomistic. However, when structure is maintained through integrating the whole and the parts, the approach is termed holistic.  It is known that the learners who use deep approaches in learning tend to enjoy the experience, retain more factual material over a longer period and demonstrate higher quality outcomes and better grades [Table 1]. ,,
Implications for practice
In this communication, we have provided a description of the theory of didactic proficiency. However, it would be useful to see how knowledge of this theory can help clinical teachers in understanding, diagnosing and solving learning difficulties in trainees.
When problems arise during learning, it could be due to a faulty compilation of the basic information that is required for understanding complex tasks. Let us take the example of learning the concept of shock. Shock arises when the oxygen supply required for normal metabolism within the organs of the body is insufficient. The cascade of cellular, biochemical and cardiovascular changes that emerges ultimately results in hypotension, multiple organ failure and in severe situations death. In addition to the pathophysiology of shock, there are different medical situations that can cause impaired oxygen transport to organs in the body. It, therefore, means that learners need a good understanding of the separate bundles of knowledge i.e pathophyisiology and etiology of impaired oxygen supply, as well as knowledge of the way these entities interact with each other in order to be able to recognise the different clinical presentations of this condition and the sort of treatment that is needed. Should the compilation of either or both of these concepts be faulty, then it could result in learners not being able to effectively understand the different types of shock and the clinical sequelae of hypoxia and hypotension in patients.
With the aid of the clinical learning cycle described in [Figure 1], clinical teachers can easily locate where faults arise and apply effective interventions such as anecdotes, analogies or stepwise descriptions of declarative knowledge to help the learners identify and reorganize the concepts that may have been compiled improperly.  The examples in Box 4-[Additional file 4] and Box 5-[Additional file 5] show how this works. The clinical teacher first identifies that the learner's problem is due to a faulty understanding of the pathophysiology of shock. Her intervention is to provide an explanation of the basic concepts of the clinical problem and uses, in this case, an analogy to highlight the different components that constitute the concept. Afterwards, she explains the causes of shock using a stepwise description of the different underlying mechanisms and also includes clinical examples. The learners can then reflect and compare their previous knowledge of the topic with the new one provided and where necessary, reorganize it.
For clinical teachers to teach effectively, it is important that they possess a basic knowledge of the educational theories and principles in addition to their domain-specific competencies. MRs on the other hand, should know of the theory of didactic proficiency as this can help them in consciously exploiting the basic tenets of education and improving their teaching and professional competencies.
[Figure 1], [Figure 2]