Constructions of Knowledge and Reflective Practice

By Glenn Regehr

Well it happened to me again … another “Stokesian” moment. This time it manifested during a CHES research rounds talk by Peter Nugus (who was visiting UBC from his home institution of McGill). Peter was offering some very cool insights into workplace-based learning, and in the process described two kinds of knowledge: reified “textbook” knowledge (which is explicitly verbalized and formalized, but abstracted and “reified” in a way that often dissociates it from meaningful practice) and “embodied” knowledge (which is deeply embedded in daily practice, but often implicit and informal and difficult to convey).

I have heard this dichotomy articulated in the past and have always felt dissatisfied with it because I see value in both versions but could not see how the two came together (some of this discontent emerged in an early Academic Medicine commentary of mine, Chickens and children do not an expert make¹). Now, however, with my new “Stokesian” lens, I think I can start to see a potential alternative conceptualization of knowledge that helps me think about differently.

I will not reiterate the background of Donald Stokes’ argument² (you can find a simplified version of it in my previous blog entry here). Suffice it to say that the general lesson I took from Stokes is that whenever we find ourselves on the horns of a dilemma in which we see two “opposites” that both seem to be desirable, the right question to ask ourselves is not which we should choose, but whether we have the dimensions right.

And it has dawned on me that the “two types” of knowledge as traditionally described might represent just such a situation. Of course we want knowledge that is “natural” and integrated and situated and can be used flexibly in the moment. And of course we want knowledge that can be articulated and sufficiently dissociated from the actual practices that we can reflect on it³, work with it conceptually (as an adaptive expert⁴), and convey it to others not only for the purposes of teaching but also to enable collective innovation.⁵ But perhaps we need not think of these two ideals as “opposites”, but rather two separate dimensions. If so, we could place them on a two dimensional plane much as Stokes did for “theory driven” and “practice driven” aspects of research. That is, we would place explicit/verbalized vs implicit/performative on one dimension and situated/flexible vs abstracted/reified on the other (as in the figure below).

In such a construction, the “textbook” knowledge (with which we have such an ambiguous relationship: our students must have it but it is not enough for effective practice and maybe expert clinicians don’t use it anyway), sits in the “explicit/reified” quadrant (upper left in the figure). And “embodied” knowledge (which is highly valued in some practice contexts as the epitome of expert performance⁶) sits in the “implicit/situated” quadrant (lower right in the figure). But, this construction also allows us to see that there is tacit/performative knowledge that actually not so desirable (lower left quadrant). This is the mindless ritualized behaviour that emerges from unreflective tradition or from the practice drift that Maria Mylopoulos and I described in a previous publication.⁷ And it allows us to see the possibility of a form of explicit knowledge that we can reflect on, but that is meaningfully embedded in daily practice and can be used flexibly (or with contextual sophistication). Herein, I believe, sits the reflective practitioner, the scholarly worker, the adaptive expert, the effective teacher.

Of course, it is not easy to dwell in this quadrant of reflective scholarly practice. As expert practitioners, sometime we just need to get the job done, so the effective use of embodied knowledge is the right way to go. The trick is finding what adaptive expertise researchers call the “optimal adaptability corridor”⁸, using automaticity when appropriate, but slowing down and reflecting in practice when necessary⁹ and on practice when possible³. Without such reflection, embodied knowledge can devolve to ritual.

And in domains where we are less that fully expert, verbal instructions are often helpful for figuring out what to do next, so more general “textbook summaries” can be vital for moving forward in a systematic and informed way. Here the trick is to recognize the limits of the abstracted, formalized instructions and to use them not as “the procedure” but as a conceptual framework for thinking about the situation (which is inevitably bound up in context and individual circumstances). Without this form of sophisticated application, the textbook instructions, too, devolve to rituals when enacted in practice.

As I think about these issues, I am once again reminded of the analogy to education scholarship. As producers of education scholarship, we are trying to create conceptual artifacts¹⁰ that can be collectively considered (peer reviewed) and built upon (in a form of collective innovation). But we must be careful to avoid promoting our ideas as “reified solutions” to educational problems that become so general that they are functionally inert in the individual contexts of meaningful practice. And as consumers of medical education scholarship, we must be careful not to treat the ideas in our literature as something we can simply take off the shelf and use without consideration of our own context.¹¹ Adapting the words of Richard Shillington, we must think of the education literature and the ideas therein as an aid to thinking, not a replacement for it.

References

1. Regehr G. Chickens and children do not an expert make. Academic Medicine. 1994 Dec;69(12):970-971.
2. Stokes DE. Pasteur’s Quadrant: Basic science and technological innovation. Washington, DC: Brookings Institute Press. 1997.
3. Schön DA. The reflective practitioner: how professionals think in action. London, UK: Temple Smith. 1983.
4. Hatano G, Inagaki K. Two courses of expertise. In H Stevenson, H Azuma, K Hakuta (Eds). Child development and education in Japan. New York, NY: Freeman. 1986.
5. Mylopoulos M, Scardamalia M. Doctors’ perspectives on their innovations in daily practice: implications for knowledge building in health care. Medical Education. 2008 Oct;42(10):975-981.
6. Dreyfus HL, Dreyfus SE. Mind over machine. New York, NY: The Free Press. 1986.
7. Regehr G, Mylopoulos M. Maintaining competence in the field: learning about practice, through practice, in practice. Journal of Continuing Education in the Health Professions. 2008 Fall;28 Suppl 1:S19-S23.
8. Mylopoulos M, Lohfeld L, Norman GR, Dhaliwal G, Eva KW. Renowned physicians’ perceptions of expert diagnostic practice. Academic Medicine. 2012 Oct;87(10):1413-1417.
9. Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Academic Medicine. 2007 Oct;82(10 Suppl):S109-S116.
10. Bereiter C. Education and mind in the knowledge age. Mahwah, NJ: Lawrence Erlbaum Associates. 2002.
11. Regehr G. A user’s guide to reading the scholarship of anesthesia education. Canadian Journal of Anaesthesia. 2012 Feb;59(2):132-135.