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  • The Application of Social and Adult Learning Theory to Training inCommunity Pediatrics, Social Justice, and Child Advocacy

    Thomas G. DeWitt, MD, FAAP

    ABSTRACT. The Issue. Perhaps the greatest challengewe face today in medical education is how to establish aconceptual framework for conveying the context of com-munity pediatrics and issues related to child health eq-uity and social justice to practicing pediatricians andpediatricians in training. This will require a new infra-structure and approach to training to allow pediatriciansto think and practice differently. The application of so-cial and adult learning theory to the development andimplementation of community pediatrics curricula willbe necessary to succeed in these endeavors. In particular,we also will need to understand the educational pro-cesses required to motivate adult learners to acquireknowledge, attitudes, and skills outside the context andframework of their previous experiences and perceivedprofessional needs. Pediatrics 2003;112:755757; adultlearning theory, social learning theory, community pedi-atrics, social justice, child advocacy, curricula, compe-tency.

    ABBREVIATIONS. RRC, Residency Review Committee; AAP,American Academy of Pediatrics.

    Traditional pediatric training in the UnitedStates and the United Kingdom remains pre-dominantly hospital based with a biomedicalfocus. Although there has been some increase in theunderstanding of the relevance of population andcommunity health training to pediatrics, there re-mains a paucity of community health instruction andcommunity-based experiences in traditional pediat-ric training in both countries. This is despite that 80%of pediatricians in the United States practice in com-munity settings and the recognition of the impact ofsocial determinants on child health outcomes.

    Before 1980, virtually no training occurred in com-munity settings. In the 1980s and early 1990s, themomentum for training in community settingsslowly progressed. In 1996, this movement gainedstrength in the United States with the implementa-tion of the Accreditation Council for Graduate Med-ical Education Pediatrics Residency Review Commit-tee (RRC) requirements for community-basedtraining. Currently, 80% to 90% of residency pro-

    grams in the United States have continuity and/orother primary care experiences in the communityand, given the RRC requirements for certification, allhave at least a 1-month community-based experi-ence. However, a disconnect remains between com-munity-based experiences and rigorous training incommunity pediatrics, preventive medicine, andpopulation-based health and child advocacy.

    In this context, a current challenge confrontingmedical education is to define priority competenciesin community pediatrics and to create training initi-atives that provide the knowledge, attitudes, andskills to fulfill these competencies. An initial frame-work to structure these educational initiatives can befound in the principles of community-oriented pri-mary care and child advocacy, as well as the Amer-ican Academy of Pediatrics (AAP) policy statementThe Pediatricians Role in Community Pediatrics.In addition, creating certification requirements incommunity pediatrics for training programs can pro-vide a mechanism for ensuring continued efforts tobridge the gaps between training and proficiency.

    It will be impossible to achieve these competencieswith training that is principally hospital based. Theinvolvement of the AAP in the Future of PediatricEducation II initiative and its policy statement oncommunity pediatrics, the Community Access toChild Health Program, and other similar efforts allhave contributed to our shift in perspective in theUnited States related to training in community pedi-atrics. Thus, there is impetus and ample opportunityto redefine pediatric training in the United States inthe context of community pediatrics, includingknowledge and skill development in issues related toequity, social justice, and child advocacy.

    Of note, this also applies to the training of subspe-cialists, including hospital-based subspecialists, whoneed to understand the realities of children and theircare in the context of the communities in which theylive. Subspecialists need to understand the broadsocial implications of the care that they provide forthe child and the family. They may not provideprimary care, but they need an in-depth appreciationof the role and function of primary care and that ofthe health system as a whole.

    The acceptance by regulatory and professional or-ganizations such as the Pediatrics RRC, the AmericanBoard of Pediatrics, and the AAP of the need forcommunity-based training in pediatrics is necessarybut not sufficient to ensure the transfer of the knowl-edge, attitudes, and skills involved in the practice of

    From the Division of General and Community Pediatrics, Cincinnati Chil-drens Hospital Medical Center, Cincinnati, Ohio.Received for publication Mar 14, 2003; accepted Mar 14, 2003.Address correspondence to Thomas Tonniges, MD, FAAP, American Acad-emy of Pediatrics, Department of Community Pediatrics, 141 NorthwestPoint Blvd, Elk Grove Village, IL 60007. E-mail: ttonniges@aap.orgPEDIATRICS (ISSN 0031 4005). Copyright 2003 by the American Acad-emy of Pediatrics.

    PEDIATRICS Vol. 112 No. 3 September 2003 755 by guest on July 14, from

  • community pediatrics. Learners must be motivatedto engage in effective community-based training ex-periences, and such experiences must successfullyengage them to sustain this motivation. Althoughnew learners may be the priority, currently practic-ing pediatricians must be similarly engaged to en-sure improved child health outcomes in a broaderperspective, provide relevant community-basedtraining sites, and serve as mentors to nurture train-ees at all levels of medical education. One of ourgreatest challenges in community pediatrics is tocreate effective educational strategies that providepracticing pediatricians and trainees with 1) knowl-edge related to the evolving contemporary morbidi-ties of childhood, 2) perspective and insight into thesocial determinants of child health and the impact ofhealth disparities and inequities on long-term healthoutcomes, and 3) skills to engage in child advocacyand the promotion of social justice and childrensrights in response to these evolving morbidities.

    Although much has been learned over the past 2decades with respect to cognitive learning in medicaleducation, many gaps in our knowledge remain con-cerning the teaching of attitudes and encouragingmotivation in adult learners. Social learning theory isperhaps most relevant to the teaching and learning ofattitudes and motivation. Simply put, social learningtheory has 2 essential concepts. The first is probablybest articulated by the traditional US approach tomedical education: See one, do one, teach one. It isprimarily a process of modeling behavior. The sec-ond concept is that motivation and the drive tomodel behavior is based on the recognition by learn-ers that a behavior modeled is important to them andtheir activity. As such, it is necessary to know how tomotivate learners at all levels of training to incorpo-rate principles and skills of community pediatricsinto practice.

    Consideration of the following practical educa-tional principles that relate to motivation in adulteducation can contribute to the successful implemen-tation of community pediatrics into traditional med-ical education curricula. It is important to note thatthese principles respond to current movements inmedical education to become more adult and learnerfocused.

    People cannot be told that they have to be motivated.However, all people can be motivated. The chal-lenge is to ensure that pediatricians motivationsare oriented in the direction of greatest relevanceand significance to child health endeavors.

    People do things for their own reasons, not for yours. Itthus is incumbent on program directors to under-stand the motivations and needs of each adultlearner as they relate to his or her individual back-ground and personal and professional plan. Withthis understanding, curricula can be modified/tailored to meet the needs of the individual, espe-cially as it occurs in experiential community-basedelements of the curriculum. Program directors alsocan work with learners to modify/change theirperspectives. One effective way to modify an in-dividuals perspective is to expose him or her

    early in his or her career to competencies that havebeen developed by individuals and institutions forwhich he or she has respect and that are deemednecessary to become a competent pediatrician.

    Create a need and develop a sense of personal respon-sibility on the part of the learner. One effective ap-proach to this, in the context of helping adultlearners think about and understand the issues ofequity and advocacy, is to have individuals con-sider these issues for each patient they see. Havethem identify and chart this assessment with anadvocacy plan through this process. Advocacythen loses its abstraction and becomes a tangiblecomponent of the care for the individual patientand his or her family.

    Structure experiences to apply to the content of life.Adult learners have evolved through a process ofpersonal and professional differentiation and havea large inventory of experiences that have influ-enced their lives. For them, theoretical, didactic,and experiential elements of curricula must beapplicable to their perceived future professionalneeds, fit into this personal history, and be prac-tical, or they will not integrate the desired knowl-edge and attitudes into the skill set that is meant tobe imparted.

    Give choices. We all are motivated by choices andwill respond to those that resonate with our pastand plans for the future. Provide choice in thecurriculum, and be prepared to modify the curric-ulum to respond to changes in the environment orinterests of the learner. Presumably, each compo-nent of the curriculum will have an impact on thelearner, and, as a result, their interests and per-ceived needs may change. Be prepared to respondto these changesespecially for trainees early intheir career development.

    Provide positive feedback. Recognition, encourage-ment, approval, and positive reinforcement willhelp to sustain the motivation of the learner. Thementors enthusiasm for the discipline of commu-nity pediatrics and issues related to equity andadvocacy is extremely important. It is equally asimportant that the adult learner see your internalmotives as sincere and value driven. Do you feelstrongly about the need to incorporate this knowl-edge, attitude, and skill set to become the bestpediatrician you can be and to provide your pa-tients the best care and opportunities they need tosucceed?

    Establish a personal relationship. The relationshipbetween mentors and learners is important. Show-ing concern about him or her and his or her future,in particular what he or she will be doing in thenear future, is a powerful tool to motivate. Engagethe learner in your own professional and, if appro-priate, personal endeavors in community pediat-rics and child advocacy.

    Create effective communication experiences. For somestudents, the topics and experiences that will beaddressed in community pediatrics (in particular,those dealing with equity, advocacy, and chil-drens rights) may seem foreign and irrelevant totheir current or future professional pursuits. The

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  • adult learner must be provided context to processand integrate information and experience. This isan important principle for experiential learning.Adult students, regardless of their level of train-ing, must be provided insight as to the relevanceof the experience, priority focus areas, what ques-tions they should ask themselves, and what theywant to accomplish before they are sent into thecommunity. After their time in the communityand periodically if this is an extended period oftime, their experiences must be processed individ-ually or in group settings to reinforce and inte-grate them into their knowledge base, attitudes,and skill set.

    The experience should relate to desired competencies.Community-based experiences should be struc-tured to relate to the competencies that are to beaddressed, and the adult learner should be able tosee the relevance of the experience to these com-petencies. Experiential learning requires ongoingdefinition of the learners responsibilities and therelevance of the related activities of the experienceto the responsibilities that will be undertaken bythe learner. Passive learning does not work interms of community-based experiences. Thelearner must participate, and the community-based experience must be structured to ensure thatthis happens. Discussion and dialogue about theexperience must incorporate the concepts that areto be imparted in a context that is relevant to thelearner.

    In addition, following the principles of experien-tial learning, every community pediatrics educa-tional experience should have structure. What is tobe taught in the larger context of the overall curric-ulum and goals, how it is to be taught, and how tomeasure the impact of the training also must bedefined before implementation of any communitypediatrics program. This is especially important inrelation to the elements of the curriculum that dealwith imparting attitudes and skill sets related tochild advocacy and the application of the principlesof social justice and childrens rights to practice. Thiscan be done, and even a 1-minute interaction withtrainees can impart these desired curricular compe-tencies. However, all faculty must be oriented tothese competencies, including those related to childadvocacy and ensuring equity in child health, andmust understand the basics of social and adult learn-ing theory if the full potential of the communitypediatrics curriculum is to be realized.

    CONCLUSIONSThe challenge we face is how to accomplish the

    formidable tasks related to developing and imple-menting community pediatrics curricula that inte-grate the breadth of what we know about social andadult learning theory. Perhaps the point of departurefor this journey could be a joint initiative by the AAPand Royal College of Paediatrics and Child Health todelineate:

    The competencies required by trainees in commu-nity pediatrics to respond to the social, political,economic, environmental, behavioral, and healthsystems determinants of child health

    The content and structure of curricula to developthese competencies and instill the knowledge andinculcate attitudes and establish the skills requiredto practice community pediatrics, including socialjustice and child advocacy

    The needs of adult learners with respect to train-ing in community pediatrics

    How to apply social and adult learning theory tomotivate and train new and practicing pediatri-cians in child advocacy and the integration of prin-ciples of social justice and childrens rights intoclinical practice and health systems

    How to structure and integrate community pedi-atrics curricula into community-based educationalexperiences using experiential and adult learningconcepts and the practitioners trained as outlinedpreviously

    The opportunity is here and now.

    SUGGESTED READINGAmerican Academy of Pediatrics, Committee on Community Health Ser-

    vices. The pediatricians role in community pediatrics. Pediatrics. 1999;103:13041306

    Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall; 1977Blanchard KH, Johnson S. The One Minute Manager. New York, NY:

    Morrow; 1982Bruner JS. The Process of Education. New York, NY: Vintage Books; 1960DeWitt TG, Roberts KB. Pediatric Education in Community Settings: A Manual.

    Arlington, VA: National Center for Educational in Maternal and ChildHealth; 1996

    Kendall JC. Principles of good practice in combining service and learning.In: Kendall JC, ed. Combining Service and Learning: A Resource Book forCommunity and Public Service, I. Raleigh, NC: National Society for Intern-ships and Experiential Education; 1990:3755

    Knowles M. The Adult Learner: A Neglected Species. 4th ed. Houston, TX: GulfPublishing Company; 1990

    Pike RW. Creative Training Techniques Handbook: Tips, Tactics, and How-Tosfor Delivering Effective Training. Minneapolis, MN: Lakewood Books; 1989

    Roberts KB, DeWitt TG. Faculty development of pediatric practitioners:complexities in teaching clinical precepting [special article]. Pediatrics.1996;97:389393

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    Pediatrics, Social Justice, and Child AdvocacyThe Application of Social and Adult Learning Theory to Training in Community

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