Luminary Learning Gastrointestinal Disorder- Issue 1

52  • LUMINARY LEARNING: GASTROINTESTINAL DISORDERS from clinical practice alongside more experienced clinicians in a classic apprenticeship model (Dornan, 2005; Swanwick, 2005) is a time-honored form of physician training, recent trends towards the ‘learning as participation’ metaphor explicitly recognize the social nature of health- care (Sfard, 1998). Lave and Wenger (1991) popularized the notion of learning by engaging in situated social activity in ‘communities of practice’. Medical learners, thus, prepare for independ- ent practice not only through acquiring knowledge by reading books or attending lectures, but by gaining access to healthcare communities—through legitimate peripheral participation—in order to work and learn with and from others, and consequently develop their professional identities (Lave and Wenger, 1991; Dornan, Boshuizen, King, and Scherpbier, 2007; Teunissen et al., 2007). There is, accordingly, a movement to promote earlier clinical experiences within undergraduate medical curricula (Diemers et al., 2007; Dornan and Bundy, 2004; Dornan, Littlewood et al., 2006; Littlewood et al., 2005). In contrast to formal curricula focused on knowledge acquisition, Eraut (2004) outlines four categories of work-based learning: (a) participation in group activities; (b) working with others; (c) assuming challenging tasks; and (d) working with clients [or patients], all of which apply to healthcare. Eraut (2000) also proposes various forms of non-formal learning at work, includ- ing: (a) unconscious implicit learning that may never reach awareness, such as how to interpret social cues, (b) conscious reactive learning that is spontaneous and responds to emergent learning opportunities, such as unexpected changes in patients’ conditions, and (c) deliberative learning , which involves actively reviewing past events and experiences and planning for future learning, as, for example, when debriefing after clinical events. As he notes, learning at work is mostly invis- ible and, thus, easily taken for granted (Eraut, 2004). Hence, the resulting knowledge is acquired without awareness and remains tacit (Eraut, 2000; Reber, 1989). Billett (2001c), however, views the differentiation between formal and informal learning critically since it suggests a situation- al determinism that de-emphasizes the role of human agency in the constructive processes of thinking-acting-learning. To the contrary, workplaces are characterized by participatory practices (Billett, 2004) that afford opportunities for individuals to engage in work activities (Billett, 2001b) within a guided learning workplace curriculum (Billett, 1996, 2000; Dornan, Arno, Hadfield, Scherpbier, and Boshuizen, 2006). Despite tendencies to emphasize formalized components of medical education, recognition that the social nature of clinical work environments affords both tacit and explicit learning has refocused clinical training on authentic patient care experiences. Learning to Practise Medicine Involves Participating in Patient Care Sociocultural learning theories stress the importance of both context and social interactions within those contexts as prerequisites for individual and collective learning (Brown, Collins, and Duguid, 1989; Durning and Artino, 2011; Eraut, 2007; Lave andWenger, 1991; Yardley, Teunissen, and Dornan, 2012) and highlight learning by doing, or experience-based learning (Ashley, Rhodes, Sari-Kouzel, Mukherjee, and Dornan, 2009; Dornan et al., 2007; Teunissen et al., 2007). Features of curricula, such as predetermined learning objectives on the one hand and, on the other hand, social interactions between medical learners and nurses, doctors, patients, and peers