Theoretical perspectives in medical education: past experience and future possibilities

Context: Pedagogical practices reflect theoretical perspectives and beliefs that people hold about learning. Perspectives on learning are important because they influence almost all decisions about curriculum, teaching and assessment. Since Flexner's 1910 report on medical education, significant changes in perspective have been evident. Yet calls for major reform of medical education may require a broader conceptualisation of the educational process.

Past and current perspectives: Medical education has emerged as a complex transformative process of socialisation into the culture and profession of medicine. Theory and research, in medical education and other fields, have contributed important understanding. Learning theories arising from behaviourist, cognitivist, humanist and social learning traditions have guided improvements in curriculum design and instruction, understanding of memory, expertise and clinical decision making, and self-directed learning approaches. Although these remain useful, additional perspectives which recognise the complexity of education that effectively fosters the development of knowledge, skills and professional identity are needed.

Future perspectives: Socio-cultural learning theories, particularly situated learning, and communities of practice offer a useful theoretical perspective. They view learning as intimately tied to context and occurring through participation and active engagement in the activities of the community. Legitimate peripheral participation describes learners' entry into the community. As learners gain skill, they assume more responsibility and move more centrally. The community, and the people and artefacts within it, are all resources for learning. Learning is both collective and individual. Social cognitive theory offers a complementary perspective on individual learning. Situated learning allows the incorporation of other learning perspectives and includes workplace learning and experiential learning. Viewing medical education through the lens of situated learning suggests teaching and learning approaches that maximise participation and build on community processes to enhance both collective and individual learning.