Creating master adaptive learners during emergency medicine clerkships

INTRODUCTION

Sir William Osler wrote, “cultivate that power of concentration which grows with its exercise, so that the attention neither flags nor wavers, but settles with bull‐dog tenacity on the subject before you.” ¹ Osler believed that we should be focusing on training a student's mind so that it can continually grow. As students transition into the clinical environment, they must shift from a performance orientation, where they strive to obtain good test scores, to a mastery orientation, where they learn to develop high levels of competency while adapting to changing contexts. ²

Given the ever‐changing nature of medicine, clinicians must therefore become self‐directed and self‐regulated learners, a skill rarely taught in preclinical training. ³ , ⁴ , ⁵ The Master Adaptive Learner (MAL) model was developed as an educational framework that teaches learners how to develop adaptive expertise. ⁶ The MAL model builds from self‐directed learning and describes the learning process in four phases (see Figure 1). During the “planning” phase, students begin by identifying gaps in knowledge that they would like to work on improving. The “learning” phase includes a period of dedicated focus on the identified knowledge gap, allowing the learner to practice critical appraisal and study in a protected space. In the “assessing” phase, the student tries out what was learned, creating real‐world muscle memory via trial and error. Finally, in the “adjusting” phase, the learner must reflect on the process as a whole, determine which information to incorporate into their routine practice, and take on a higher‐level perspective identifying the interplay between this newly acquired skill and the system as a whole. In parallel, the MAL model emphasizes cultivating characteristics of curiosity, motivation, resiliency, and a growth mindset as batteries to drivelearning, and coaching as the rheostat to keep the process moving forward. ⁶

FIGURE 1.

The Master Adaptive Learner (MAL) model utilizes four phases or “gears” that move a novice on their path towards adaptive expertise. The phases are planning, learning, assessing, and adjusting and are powered by the four characteristic traits of curiosity, motivation, resilience, and a growth mindset, with coaching as a rheostat.

The emergency department (ED) is an ideal place to cultivate master adaptive clinicians. ⁷ However, the current organization of emergency medicine (EM) clerkships may not be ideally structured to facilitate the MAL model. Nevertheless, with some adjustment to an EM clerkship curriculum using MAL model principles, optimal learning on rotation can occur. Here, we discuss concrete steps of how an EM clerkship can be reimagined around the idea of creating MALs.

IDENTIFY INTRINSIC MOTIVATION FOR MASTER ADAPTIVE LEARNING

To incorporate the MAL model into an EM clerkship, clerkship directors should first utilize a learner's intrinsic motivation to incite positive change and growth during the rotation. Studies have demonstrated that utilizing a student's own intrinsic motivation is associated with higher rates of self‐directed and lifelong learning. ⁸ To encourage our learners to work through the four phases of the MAL model, we need to help them find and foster their own intrinsic motivation to do so. This can be achieved by asking students what drives them to learn and helping them find both internal and external focuses that align with the mission of the EM clerkship.

CREATING LEARNER‐GUIDED GOALS

To incorporate the planning phase of the MAL model into the EM clerkship, learners' motivation and interests should shape their clerkship goals. ⁹ While clerkship directors should have preidentified overarching rotation goals, they should also provide direction for students to develop their own specific goals for the rotation. ¹⁰ With this, they gain experience in setting realistic goals that align with their motivations. ¹⁰ There are several models that exist to help facilitate this, including the informed self‐assessment in Sargeant et al. ¹¹ wherein learners are guided to utilize internal and external data to inform their own self‐regulation. One study demonstrated that learners were highly engaged within a clerkship that had them set weekly goals. ¹² Learner‐guided goals should be discussed from Day 1, followed by frequent check‐ins both during and after the rotation to ensure these goals are met.

ENCOURAGE CRITICAL THINKING

The ED is a busy environment, and it is important to ensure students utilize good learning practices in their clinical shifts. This involves using patient cases to learn midshift by utilizing critical thinking practices. Rather than merely reciting the same canned “serious differential diagnoses” for classic presentations (e.g., chest pain, headache), students should analyze each particular case to come up with a unique differential diagnosis specific to that case (e.g., “Why is carbon monoxide poisoning not on your differential for this patient's headache?”). This best represents the assessing phase of the MAL model and can also be accomplished by encouraging students to do literature searches on shift and weighing the evidence of the case. However, critical thinking informs every phase of the MAL model, as MAL cannot occur while on autopilot. ⁶

FOSTER THE DEVELOPMENT OF STRONG ON‐SHIFT LEARNING HABITS

Another important way to practice the MAL model during an EM clerkship is by instilling good on‐shift habits. Many faculty members engage students in a patient presentation, but fall short of teaching them during other parts of the patient encounter. To help a student through the learning phase of the MAL model, faculty must make a habit of actively engaging in all parts of the patient's visit. This can help make commonplace acts such as taking time to prepare before giving a presentation, reassessment of patients' conditions after interventions, following up on patients after disposition, and asking for end‐of‐shift feedback. This can aid in the MAL assessing and adjusting phases, as learners refine their presentations, reflect on the effectiveness of their plans, and aim to improve for the next patient.

MOVE TO A COACHING MODEL OF FEEDBACK

Central to the development of a learning culture is daily feedback in the context of coaching, the rheostat in the MAL model. ¹³ , ¹⁴ Faculty and clerkship leadership should model and encourage the importance of critique for self‐improvement from both intrinsic and extrinsic sources. Like an athlete, each shift in the department should be viewed by the learner as a practice. During that time, learners are provided with discrete points to adjust and improve their performance, much like a coach provides drills or key adjustments to their athletes knowing that the first attempt may not (and likely will not) be perfect. Central to the effectiveness of feedback is the openness to self‐reflection by the learner. During feedback, learners should be positively encouraged to self‐reflect on their own performance and how it relates to their goals, helping them through the assessing phase of the MAL model.

SEPARATE FEEDBACK FROM ASSESSMENT

Separating feedback from summative assessment allows learners to gain from the feedback they receive without being on high alert that the identified growth areas will lead to poor grades. ¹⁴ The overall summative assessment of the learner's performance may be derived from a larger, more holistic pool of data, such as longitudinal performance over time, satisfactory completion of learner‐guided goals, aptitude and engagement during asynchronous sessions, or possibly scores on a clerkship exam. While daily feedback can be an important part of a student's assessing phase of the MAL model, having summative assessments is also important to allow students to restart the cycle over by planning the next skills they need to acquire. The distinction between feedback and assessment and how final grades will be calculated should be made clear to the learners from the rotation beginning to alleviate any concerns with receiving feedback. Preceptors should reinforce that daily feedback is intended to be “low‐stakes” and is not meant to “test” or assess. ¹⁴ By integrating self‐reflection and goals into feedback, and by making distinctions between feedback and assessment, we can foster an environment that encourages growth and lifelong learning in line with a student's own intrinsic motivation.

CREATE A DELIBERATE APPRENTICESHIP MODEL

EM clerkships often struggle with tailoring learning experiences to medical students due to the variability in clinical experience, wide varieties of student skill levels, and limited follow‐up with the same teacher/mentor due to the shift work. A standard EM clerkship schedule makes it difficult for students to iteratively improve their skills with feedback, as new providers must get acclimated to them each shift and the trust needed to ask for and receive feedback has not yet been developed. Instead, students may hide their weaknesses and play up their strengths rather than seek to demonstrate a growth mindset. This limits a student's ability to go through the assessing and learning phases of the MAL model, which often requires the trust of longitudinal mentorship to accomplish.

EM presents a rich environment for apprenticeship, where faculty physicians work alongside residents and students to quickly see the queue of patients. By making a schedule that deliberately assigns clerkship students to work with the same senior residents or faculty over the course of multiple shifts (a model known as deliberate apprenticeship), students may feel less overwhelmed in the clinical environment and be better able to develop adaptive expertise utilizing the MAL model while in the ED. ¹⁵ , ¹⁶

ENCOURAGE AUTONOMY

Allowing for autonomy to grow during the EM clerkship can help motivate learners to identify their own knowledge gaps (the planning phase) and self‐reflect on how to improve. ⁹ Autonomy with appropriate supervision allows students to take ownership of the full patient encounter and can aid in their overall growth during the rotation. To do so, instructors should allow for meaningful task variation, moving away from rigid structures for patient encounters and workups to allow learners to develop their own patient care skills. ¹⁷ Placing this responsibility on the student can improve their engagement with the patient encounter and work toward activating their own intrinsic motivation to learn. ¹⁸ , ¹⁹ By giving students autonomy over the patient encounter (what they want to do and how they want to do it), rather than telling them what the treatment plan will be, they will be able to see what works and does not work, helping them move through the assessing and adjusting phases of the MAL model.

MODEL LIFELONG LEARNING

The four characteristics, or “batteries,” necessary to succeed in the MAL model (curiosity, motivation, resiliency, and a growth mindset) should be represented within the training environment. ⁶ Therefore, it is important for faculty and residents in the ED to model these four characteristics themselves over the course of a shift with the students. This can be accomplished by having faculty point out the knowledge gaps that are identified during a shift and how they formulate a plan in the moment to overcome these gaps. A faculty member can then follow up by assessing the application of the new knowledge in real time along with the learner.

The ideal implementation of the MAL model would include identifying faculty and residents who are noted for their teaching ability and who would routinely demonstrate the same four characteristics asked of the students: growth mindset, motivation, curiosity, and resiliency. ²⁰ Creating faculty development modules and a residents‐as‐teacher curriculum grounded in MAL principles will also be good for the entire ED, as it will provide a shared language for continual improvement that can help ensure all learners are well‐guided along their journey.

Example

Alex, a fourth‐year medical student applying into internal medicine, is beginning his mandatory EM clerkship rotation (see Figure 2). During his orientation, the clerkship director asks him about his goals and how the clerkship team can help him succeed. Alex is not prepared for this question but is happy to have an opportunity to reflect on what he feels would be best to achieve during the rotation. The clerkship director and Alex then develop shared goals and he decides to try to present at least five potential diagnoses during every presentation (planning phase). Before his first few shifts, Alex prepares by reading articles on “the 3‐minute EM student presentation” for common chief complaints to meet his goal (learning phase). After his shifts are complete, he has conversations about how the shift went with his mentor coach, along with further encouragement for improvement during the rotation (assessing phase). He then determines which new skills are best for himself and for the clinical environment as a whole and incorporates what he learns into his routine practice for his next rotation (adjusting phase). Alex now feels driven by his success with self‐improvement and is ready to take these learning skills with him as he completes his training and goes out into practice.

FIGURE 2.

Example of a medical student utilizing the Master Adaptive Learner (MAL) model to improve on their intrinsically motivated goal of better differential diagnoses.

CONCLUSIONS

Implementing a MAL model curriculum into an EM clerkship may require reimagining many of the traditional aspects of clerkship structure, but the benefits include fostering lifelong learning skills in students early in their career. Through the concrete steps outlined here, we can encourage adaptable learning and foster the development of a more robust, prepared EM physician workforce, ready to tackle whatever challenges lie ahead.

AUTHOR CONTRIBUTIONS

All authors contributed to the study concept and design, literature search, commentary and review, drafting of the manuscript, and critical revision of the manuscript.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

Carmelli G, Fullmer R, Goodrich M, et al. Creating master adaptive learners during emergency medicine clerkships. AEM Educ Train. 2022;6:e10829. doi: 10.1002/aet2.10829