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Guest Perspective: Are We Serious About Lifelong Learning?

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Prof. Hendricson PhotoBy 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 

Curious 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.

But remaining 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 lifelong learning. 

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. 

Schön contended 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.

The reflective judgment process (RJP) has been described in various contexts using different terminology for centuries, but here are the key elements:

  • Identify issues pertinent to a problem, error or dilemma.
  • Identify, explore and prioritize causal factors.
  • Retrieve and assess knowledge needed for alternative actions.
  • Compare strengths and limitations of options.
  • Implement the option most likely to resolve the problem. 
  • Appraise 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 ideas.  
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). 

Let’s explore 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 encapsulated data. 

When confronted 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. 

If students’ 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). 

An individual 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). 

Together, these 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 after graduation. 

1. Adjust the faculty composition.
The faculty 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 teaching.

The nontenured, 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 education research.
All 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 teach.
All students 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.
Schön 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. Best wishes!

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Bransford JD, Brown AL, Cocking RR. (Eds.) How people learn: brain, mind, experience and school. Washington, DC: National Academy Press, 2000. 
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Nyberg L, Persson J, Habib R, Tulving E, et al. Large scale neurocognitive networks underlying episodic memory. J Cogn Neurosci 2000;12(1):163-73. 
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Premkumar K, Pahwa P, Banerjee A, et al. Changes in self-directed learning readiness in dental students: a mixed-methods study. J Dent Educ 2014;78(6):934-43. 
Zeegers P. Approaches to learning in science: longitudinal study. Br J Educ Psychol 2001;71(Pt 1):115-32.


Wow! This is a powerful and inspiring discourse on the importance of lifelong learning! I particularly appreciate the concept of "triple threat" faculty members enhancing the learning environment and serving as role models for our future dental and medical colleagues. Thank you, Dr. Hendricson, for the wonderful article!
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