By William D.
Hendricson, M.A., M.S., Assistant Dean, Educational and Faculty Development,
University of Texas Health Science Center at San Antonio School of Dentistry
skepticism. An eagerness to learn. Acquiring new skills that enrich practice.
As dentists progress through their careers, these activities are what lifelong
learning is all about.
an active learner throughout one’s career is not as easy as advocating this
behavior. Lifelong learning requires effective meta-cognition—the mental
processes that allow self-monitoring of learning, behavior and performance, and
most critically, sensing that “something needs to be enhanced, or an aspect of
practice must be re-examined” (Mathan & Koedinger, 2005). Ideally,
graduates will enter the workforce with the level of curious skepticism that
makes them uneasy when a new technology lacks research support or dismayed when
a patient has a disappointing outcome. Unsettled by these uncertainties and
deficiencies, they will be compelled to search for explanations—the heart of
To see why, let’s
take a trip back to the 1980s when Donald Schön’s The Reflective Practitioner: How Professionals Think in Action was
hot stuff in academic circles. Schön’s reflection in action concepts blended
with Chris Argyris’ single and double loop learning theory (Argyris, 1976)
became bedrock principles of organizational management and professional
development theory. In single loop learning, individuals encounter errors and
fix them as they occur (i.e., pothole filling), but still rely on the same
policies and techniques even though the potholes continually re-occur. This
person (or an entire institution) has only one way to proceed: Patch the
pothole and move on. In double loop learning, the person takes a second look,
analyzes causal factors and creates new procedures so the error does not
continue to pop up. In other words, the learner explores an alternative
pathway, involving a new way to “see” the problem.
that true professional growth does not begin until a person not only sees
events but begins to examine them with a skeptical eye and becomes courageous
enough to doubt his or her actions. This internal skepticism is the heart of
the “reflective judgment process”—a way of critically self-monitoring one’s
journey throughout one’s professional life.
judgment process (RJP) has been described in various contexts using different
terminology for centuries, but here are the key elements:
issues pertinent to a problem, error or dilemma.
explore and prioritize causal factors.
and assess knowledge needed for alternative actions.
strengths and limitations of options.
the option most likely to resolve the problem.
results and continue to modify.
In the 40 years
since the “reflective practitioner” burst onto the scene, virtually all health
professions have adopted elements of the concept and worked the RJP into their
descriptions of what it means to be a professional in their discipline and how
to “think and self-monitor” as a professional. Health professions also have
incorporated these concepts into accreditation standards, often rephrased as
the capacity for self-assessment or critical thinking and used as the framework
and rationale for self-directed learning. However, it should be noted that
difficulties in translating the theories of Schön and Argyris into practice led
to criticism (Greenwood, 1993).
In the same
time period, William Perry’s Forms of
Ethical and Intellectual Development in the College Years kept the
conversation lively at academic cocktail parties. Perry studied intellectual
development in college students to learn how students perceived knowledge and
how they interacted with knowledge, especially how they conceptualized “truth.”
Perry found that students progressed through a six-step maturation:
1. Dualism: rigid black or white thought,
with active resistance and distress when confronted with alternative
2. Early Multiplicity: begrudging
awareness of shades of gray. I know there are alternative visions of reality
out there, but I don’t want to hear them.
3. Advanced Multiplicity: cautious acceptance
of shades of gray. It’s okay if some people’s beliefs differ from mine, as long
as they do not affect me.
4. Contextual Relativism: understanding
that context influences behavior and decision-making; willingness to assess
actions in light of circumstances.
5. Skepticism: questioning; confidence in
self, but criticism of others; reliance on empirical data; dismissiveness of
anecdotal, subjective or emotional reports.
6. Reflective Judgment: willingness to be
self-critical and to change behavior after recognizing fallacies in knowledge,
assumptions or behaviors.
Why was Perry’s
research so controversial? Perry reported that most students never evolved
beyond the low rungs of his hierarchy. He found that dualistic thinking and
narrow-mindedness abounded throughout the hallowed halls of academia. Yikes! Research
over ensuing decades pretty much replicated his findings. The majority of
university students, including those in graduate programs and arduous science
or engineering programs, exhibited thinking that rarely exceeded step 3 and
hardly ever reached the levels of skepticism or reflective judgment (Felder
& Brent, 2004).
students’ conceptualization of knowledge a little deeper because it’s critical
to lifelong learning. Students in the first two years of dental school sponge
encyclopedic information from lectures, textbooks and online sources. They
often possess far more factoid nodes than their professors (Nyberg et al.,
2000), but this information is compartmentalized without linkages. It’s just
with a new problem, novice learners try to solve it by applying isolated bits
of information in a laborious trial and error process. To move beyond compartmentalized thought, some students
learn to convert these unorganized data fragments into chains of spiderweb knowledge, which has utility
because it has been tempered with insight and knowledge of outcomes gleaned
from experience and reflection. Unfortunately, many students are inconsistently
exposed to teaching/learning methods that allow them to practice “connecting
the dots”—a sometimes messy and nonlinear learning process, which eventually
leads to the spiderweb of networked knowledge that is integral to expertise.
cognitive development stalls at compartmentalization, they may graduate with
the perception that “knowing” is limited to comprehension of a static database
of facts. They may also have little experience with broadening that database or
examining its merits. Additionally—and this gets back to Perry’s theories and
the educational psychologists’ concept of constructivism (Bransford, Brown
& Cocking [Eds.], 2000)—students may not perceive that information can be
personalized—that it can be shaped and augmented by modifying their
understanding of a factoid in light of their own experiences and reflections.
This is a key step in forming elaborated
knowledge, which carries personal meaning and is the trigger for long-term
memory (Bordage, 1994).
with a passive approach to information management is not likely to pursue
lifelong learning aggressively. Results from the Study Processes Questionnaire
(SPQ) and Approaches and Study Skills Inventory for Students (ASSIST), both
widely used learning process measurements, indicate that a high percentage of
university, graduate and professional students have a database concept of
knowledge and see learning as a rote memorization process (Biggs et al., 2001;
Zeegers, 2001; Emilia et al., 2012).
data suggest that lifelong learning, which requires Schön’s self-reflective
skepticism, sophisticated intellectual maturity and capacity for self-directed
learning, is not a skill that comes automatically with the diploma at
graduation (Premkumar et al., 2014). If that’s the case, how can we cultivate
lifelong learning as a way of professional life?
There have been
reviews of teaching/learning strategies that promote mental capacities integral
to the curious mind (Hendricson et al., 2006). These strategies involve active
learning—in various forms—as a frequent, mainstream component of the
curriculum. Instead of rehashing these strategies, let’s look at four
infrastructure ideas for enhancing students’ readiness to be active learners
1. Adjust the faculty composition.
team within dental academia needs to swing back to a roster that includes more
tenure-track “triple threat” (teaching, research, service) teammates, versus
the current trend of composing the roster with nontenure, clinical-track
instructors primarily focusing on teaching. I know this perspective will be
mocked as economically unfeasible and “out of step with reality,” especially in
administrative suites. But if dental educators are serious about cultivating
lifelong learning in the profession, students need to be surrounded with
faculty role models who are deeply engaged in research and service as well as
and often part-time, faculty across the continent are terrific—eager to teach,
great with students, full of clinical wisdom, and they are often working
full-time schedules on half-time pay to share their expertise. I have consulted
with over 60 North American dental schools, and I can tell you, they do not
have the time, and were not hired, to serve as triple-threat role models.
Serving as a role model requires being immersed in professional growth
activities—presenting at professional meetings, publishing, writing grants,
consulting at other schools, conducting continuing education, serving on
editorial boards, being association officers and pursuing advanced degrees.
2. Engage all students in dental
students should matriculate with a “curious-mind” issue that they commit to
exploring during dental school. This issue should be submitted on the
application. With faculty mentorship, students refine and sharpen the question
in Year 1, explore it in Years 2 and 3, and in Year 4, present what they have
learned. In a pilot of this concept at San Antonio, we established a Research
in Dental Education (RIDE) program four years ago that couples faculty mentors
with students who seek to answer questions about educational controversies.
Forty students have explored dental education issues in collaboration with
faculty, resulting in 60 presentations at state and national meetings. Several
projects have expanded, spiderweb-like, as new research questions evolve. For
me, this program emulates the process of lifelong learning.
3. Give all students opportunities to
should experience a semester-long teaching rotation during dental school. There
is no stronger catalyst for learning and “getting up to speed” than preparing
to teach. For example, in the Teaching Honors Program (THP) at our school, THP
students complete a teaching assistant (TA) rotation in the 1 restorative
dentistry simulation lab. THP seniors also complete clinical “Faculty for a Day”
rotations, where they take the place of a faculty member in one of our group
practices and supervise third-year students. In self-assessments after these
rotations, students realize that teachers need finger-tip knowledge to
spontaneously answer students’ questions and provide suggestions. The rotations
stimulate student-instructors to study up on cases they will cover the next day
or on procedures in the next lab, and the experience builds admiration and
appreciation for “all the prep that faculty must do before and after school
that we never see.”
4. Model reflective behaviors.
emphasized the importance of role modeling in cultivating “reflection in action.”
Predoctoral dental education is unlike education in other health professions in
that students perform the dentistry and faculty serve as coaches. Dental
students need more experience working in patient care environments where they
see dentists providing treatment and then debriefing the outcomes. On the
medical/nursing side, morning reports, chart reviews, noon conferences, case
management team huddles and the rounding process provide opportunities for
students to see patient status and outcomes discussed among physicians,
residents and nurses. This method argues for more clinical experience in
community settings and more seminars at the dental school clinic where faculty
candidly debrief their own cases in front of students, discussing flaws and alternatives—not
just trophy cases. Also, why not allocate just one hour a week for case outcome
conferences so students can experience candid analysis of patient management as
a routine part of the patient-care process? These after-action discussions
often occur in dental residency programs, but the majority of predoctoral
students do not participate in advanced training and may only get this
experience episodically in a once-a-year, formalized case presentation for a
grade. Useful—but too infrequent.
One of the
issues with lifelong learning is that it is so darned hard to predict when
someone has the capacity for it. For many people, including highly trained,
intelligent professional-school graduates, self-directed learning just does not
come naturally. However, it is a capacity that can be cultivated if certain
events occur frequently during the training phase as discussed above, and if
people have the underlying disposition to allow curious skepticism to be part
of their professional responsibility.
There is a test
of lifelong-learning capacity known as the Effective Lifelong Learning
Inventory (ELLI). It was developed by Crick and colleagues at the University of
Bristol (2004) and is widely used internationally in higher education and the
workplace. The ELLI measures an individual’s readiness for lifelong learning on
seven dimensions, including critical curiosity, strategic awareness and
learning resilience. The test results can be used for individual and group
orientation or counseling on self-reflection, the reflection judgment process,
concept of knowledge and the role of continuous learning in professional life.
Using the ELLI with students and faculty at your school might be a way to begin
a discussion of ways to promote curious skepticism among your dentists-in-training.
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