For the fourth year, we are collaborating with the ALiEM Faculty Incubator Program to serialize another volume of Educational Theory made Practical. The Faculty Incubator program a year-long professional development program for educators, which enrolls members into a small, 30-person, mentored digital community of practice (you can learn more here); and, as part of the program, teams of 2-3 participants author a primer on a key education theory, practically linking the abstract to practical scenarios.
They have published their first and second e-book compendium of this blog series and you can find the Volume 3 posts here (the e-book is in progress!) As with the previous iterations, final versions of each primer will be complied into a free eBook to be shared with the health professions education community.
Your Mission if you Choose to Accept it:
The ALiEM Faculty Incubator Program would like to invite you to peer review each post. Using your comments, they will refine each primer. No suggestion is too big or small – they want to know what was missed or misrepresented. Whether you notice a spelling or grammatical mistake, or want to suggest a preferred case scenario that better demonstrates the theory, they welcome all feedback! (Note: The blog posts themselves will remain unchanged.)
This is the tenth and FINAL post of Volume 4. You can find the previous posts here: Cognitive Load Theory; Epstein’s Mindful Practitioner; Joplin’s Five-stage Model of Experiential Learning; Maslow’s Hierarchy of Needs; Miller’s Pyramid; Multiple Resource Theory; Prototype Theory; Self Regulated Learning Theory and Siu & Reiter’s Tau Approach.
Kolb’s Experiential Learning Theory
Authors: Anita Thomas (@yourbabydoctor), Brian Barbas (@DrBBarbas)
Editor: Benjamin H. Schnapp (@schnappadap)
Main Authors or Originators: David Kolb
Part 1: The Hook
On a busy Sunday evening in your emergency department, Jared, a fourth year medical student, precepts a patient with Dr. Jones.
“…so, in assessment, Sarah is a 2 year old female with a 2 cm linear forehead laceration, that I think requires suture repair.”
“Sounds good,” Dr. Jones replies. Since she’s never worked with Jared before, she asks, “Do you feel comfortable suturing?”
Jared replies, “Definitely, I’ve sutured a bunch on other rotations.”
Dr. Jones decides to trust Jared’s self assessment. “Okay, I’ll order LET (lidocaine/epinephrine/tetracaine) as a topical anesthetic, intranasal midazolam, and have the nurse administer the midazolam about 5 minutes before we go in.”
Dr. Jones sees several other patients and realizes that it has been about 45 minutes since LET was applied to Sarah’s laceration. She walks into the patient’s room as the nurse is administering intranasal midazolam and sets up the laceration tray along with Jared.
After burrito-wrapping Sarah and attempting to distract her with her parents’ phones, it becomes apparent that Sarah will likely scream throughout the procedure. Her parents are intermittently in tears and angry with Dr. Jones and the medical team.
“He told us that she would be completely asleep!” Sarah’s parents exclaim pointing at Jared.
Dr. Jones attempts to de-escalate the situation by highlighting the amnestic effects of midazolam and that Sarah likely does not like being restrained. She reiterates that this is a common anxiolytic in this age group for this procedure and that she would not recommend full sedation for this.
While Dr. Jones is talking to Sarah’s parents, Jared begins irrigating Sarah’s laceration before injecting lidocaine, causing Sarah to cry harder. At this point, Dr. Jones says, “I think it would be better if I did the repair.”
Jared is confused, but pushes the laceration tray towards Dr. Jones. He watches the rest of the procedure silently, annoyed and feeling out of place.
After the laceration repair, Dr. Jones rushes out of the room to see another patient. Jared hangs back with Sarah and her parents, discussing post laceration repair care. He steps out to grab a popsicle for Sarah. He planned to discuss what happened, but by the time he had a moment to grab Dr. Jones, she had left for the day.
Both of them were left wondering how the situation could have gone better.
Part 2: The Meat
Overview
Kolb’s experiential learning theory (ELT) may seem familiar, as the educational theory is what much of medical training is modeled on. The four steps of Kolb’s theory are concrete experience, reflective observation, abstract conceptualization, and active experimentation. Each of these steps can be applied to each patient and learning experience.
Kolb intended his cycle to be sequential in order to truly solidify learning. For example, a medical student may have had a concrete experience where a clinician treated a patient with albuterol. Reflective observation would entail reviewing that encounter and looking for clues as to why that albuterol was ordered and how it affected the patient. That medical student may look up the pathophysiology of the particular disease (in this case asthma) and study the use of albuterol in the treatment of asthma and in other diseases (abstract conceptualization). Active experimentation would involve that medical student suggesting use of albuterol in a subsequent patient encounter where they believe the patient has chronic obstructive pulmonary disease (COPD), a disease closely related to asthma.
While Kolb’s theory should occur sequentially, it can require different skill sets at different points in the learning circle, thus the skill sets may not evolve occur sequentially. Looking at the circle (Figure 1), learning processes that are directly across from each other are related. Concrete experience and abstract conceptualization can be viewed as grasping experiences whereas reflective observation and active experimentation as transforming experiences1. Additionally, deliberately applying Kolb’s theory may require intrinsic motivation for the learner or resident, or some sort of extrinsic facilitation through a test or a supervising physician.
According to Kolb, individuals may have preferred learning styles within the cycle. Some resident trainees may learn best through concrete experience, like observing or participating in a resuscitation for the first time. Others may prefer to learn by active conceptualization, such as thinking about the pathophysiology of a particular type of shock, rather than treating it firsthand. Similarly, reflective observers prefer learning by watching more senior physicians perform a laceration repair whereas active experimenters might dive right into the repair themselves. It can be difficult to engage opposite learning processes simultaneously, so most learners pick one process.2 For example, a learner would have a hard time reading about how to swim (abstract conceptualization) at the same time as trying out how to swim (concrete experience).
Background
While first published in 1984 by educational theorist David A. Kolb, the influences behind experiential learning theory can be found in the works of many before him including John Dewey, Kurt Lewin, Jean Piaget, and many more.
The concept of experiential learning can be seen as far back as the teachings of Confucious around 450 BC: “Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand.”
In the early 20th century, this concept took hold in modern educational theory. During this time period, psychologist John Dewey posited that “there is an intimate and necessary relation between the process of actual experience and education.4”
During the 1940s, while studying group dynamics, social psychologist Kurt Lewin and his colleagues made note of the experiential learning process at work. While exploring the conversation about “the differences of interpretation and observation of the events by those who participated in them,” Lewin observed that learning is best facilitated in a setting in which there is an active balance between immediate concrete experiences of learners and the detached analytic feedback of the group.1 This lead to the creation of the National Training Laboratory in Group Development, of which inspired the theory behind the learning cycle at the base of Kolb’s ELT.1
Meanwhile, Piaget’s work exploring the cognitive-development process in childhood lead to the development of the theory of learning. Through his studies, Piaget argued that “intelligence arises as a product of the interactions between the person and his or her environment,”1 In other words, as Kolb summarized Piaget’s work, “intelligence is shaped by experience.”1
After nearly 20 years of studying the field of experiential learning, Kolb set out to develop a theory that “integrate the common themes” in the works of Dewey, Lewin, Piaget and others into a singular theory which he called Experiential Learning Theory (ELT) to emphasize the central role that experience plays in the learning process.1
Modern takes or advances
Experiential learning is essential to post-graduate medical education. All of residency is an experiential learning process involving concrete experience, reflective observation, abstract conceptualization, and active experimentation. Kolb’s theory is so ingrained within medical education that most searches for practical application of Kolb’s ELT are related to medical education’s clinical application (i.e. patient/physician experiences). Every patient interaction, new procedure, and bedside teaching moment with a medical students is an opportunity to witness Kolb’s ELT. Residents have the opportunity to have their concrete experience, reflect on the experience, think of a plan to improve and apply the changes on the next similar experience. In studies of resident education, Kolb’s ELT serves as at least a partial explanation for what is retained, highlighting the importance of residency experiences of patient encounters for trainees.5, 6
Other examples of where this theory might apply in both the classroom & clinical setting
Clinically: Kolb’s theory of experiential learning can be applied to almost any patient encounter, provided that clinicians (trainees from medical students to residents to fellows) are engaging in the steps. Reflection may result from known medical errors, but the goal is for it to occur after almost every patient encounter. For example, a trainee might attempt to reduce a pediatric nursemaid’s elbow, which may have actually been a type 1 supracondylar fracture. Discovering this on x-ray may lead to reflection and abstract conceptualization of why this patient had a fracture rather than a nursemaid’s elbow. Active experimentation would then practiced on the next pediatric patient with elbow pain.
Classroom: Kolb’s theory applies well to the simulation environment. Starting with a simulated patient scenario provides for a concrete experience. Debriefing encapsulates reflective observation and abstract conceptualization. Debriefings often start with open ended questions such as “How did that feel?” allowing for the group to engage in reflective observation. Reviewing and reflecting on that shared experience ideally results in abstract conceptualization. For instance, a facilitator may start a discussion with, “Tell me about how you were thinking about fluids for this patient,” which can lead to a shared mental model of why fluids were desired and in what quantity (abstract conceptualization). Active experimentation can then be accomplished in subsequent simulations and in real patient encounters. Simulation can allow for all four steps of Kolb’s theory by stopping participants when an error is made, offering time for active reflection and learning, and repeating the simulation from the beginning so that active experimentation of what was just learned can be put into practice, a technique called rapid cycle debrief practice.9
Additionally, Kolb’s theory can be applied to morbidity and mortality conferences, which start with a concrete clinical experience that has a suboptimal outcome, then allow for group reflective observation and abstract conceptualization about more ideal management as these cases are generally discussed in a group setting. For example, if a patient with a headache after a concussion was ultimately diagnosed with a brain tumor after several clinical visits, each visit is a concrete clinical experience for the primary clinician. Each visit is generally reviewed during a morbidity and mortality conference, thus creating a shared mental model for all conference attendees. Generally, groups then reflect on each visit and discuss the clinical background. Often, other clinicians will utilize abstract conceptualization with comments like “Well, if I had been the primary doctor, then I may have ordered head imaging because of multiple visits” or “I probably would have treated the patient similarly, because of lack of concerning symptoms.” The purpose of morbidity and mortality conferences is to reflect and increase awareness of such cases, such that attendees keep them in mind when seeing similar patients in the future (active experimentation).
Kolb can be utilized as a framework for workshops as well. Structuring workshops with breakout sessions allows reflection for current practice allows participants to reflect on their concrete experience and provides time to conceptualize ways to change/improve their practice. Depending on the workshop concept, a workshop may allow for active experimentation as well. For example, in running a quality improvement introduction workshop, participants can be asked to reflect on an opportunity for improvement in their clinical environment and share with a small group for ideas for improvement, which allows for learning opportunities and future active experimentation.
Annotated Bibliography of Key Papers
Kolb DA. Experiential learning: Experience as the source of learning and development Second Edition. Upper Saddle River, NJ: Pearson Education, Inc; 2015.1
The first edition (1984) of this book introduced Kolb’s experiential learning theory. This updated edition still displays the original underlying structure behind the theory, while also discussing continued research supporting the theory over the past 30+ years, addressing concerns behind the original publication and displaying current examples of experiential learning both in the field and in the classroom.
Kolb DA, Boyatzis RE, Mainemelis C . Experiential learning theory: Previous research and new directions. In R. J. Sternberg & L.-f. Zhang (Eds.), The educational psychology series. Perspectives on thinking, learning, and cognitive styles. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 2004: 227-247.2
This chapter goes over the basics of ELT and how different learning styles fit into them. It a useful source to dive into the how learners reconcile conflicts within the learning processes, known as learning styles, and include accommodating, diverging, assimilating, and converging. It is a succinct overview of ELT and describes how learning styles are shaped.
Yardley S, Teunissen PW, Dornan T. Experiential learning: AMEE guide No. 63. Medical Teacher. 2012;34:102-115.11
This paper goes over various theories behind experiential learning as it relates to medical education, including the background of experiential learning. Importantly, this paper discusses what other theories have added to Kolb’s ELT and points out that in medical teaching, implementation of Kolb’s theory often goes without support at each stage, which can be detrimental to the learner. Support for both learners’ conditions and processes for experiential learning can lead to improved outcomes of the learning.
Limitations
It can be difficult to accomplish all of Kolb’s theory in the moment as it requires deliberate reflection and repeated experiences. In an emergent situation, like performing CPR on a dying patient, there might not be time to guide a learner through reflection, conceptualization, and experimentation. Additionally, the goal for a learner would be for the Kolb cycle to be self-sustaining, but the cycle does require some level of intrinsic motivation unless there is an external facilitator. For a trainee who might be burned out, Kolb’s theory may not be relevant as the learner may not be in a state to tackle a multi-stage learning cycle.
Additionally, while Kolb’s learning cycle shows a continuous progression of the cycle, in reality, sometimes different stages might occur at the same time which can be difficult to predict. It may be useful to lay out Kolb’s learning theory when engaging with a trainee to employ a shared mental model for learning, such as how to approach a procedure.
Lastly, Kolb’s ELT does not consider the social context of the learning, including power dynamics between teachers and learners.11 If a medical student is fearful of being reprimanded in front of the entire team, that might change their learning process. Additionally, it does not take into account racial or gender based dynamics. A female intern of color might have a different concrete experience than a male caucasian intern. Effects of prior learning experiences might not be directly called out in Kolb’s ELT, but they may play a large role in shaping a further learning for a trainee.
Part 3: The Denouement
A few days later, Jared is on shift again and eagerly picks up another facial laceration in a 3 year old patient. He presents to Dr. Jones:
“Hi Dr. Jones, I have a 3 year old male with a 2 cm forehead laceration that needs repair. I’ve already discussed intranasal midazolam use with the family and the nurse applied LET. I feel comfortable repairing with your supervision.”
Dr. Jones nods and gestures towards Jared to sit. “I’ve been thinking about the laceration we had together a few days ago (concrete experience). How did that feel to you?” (Dr. Jones allows for reflective observation).
“It was really stressful for me because I felt like I didn’t get a chance to try,” Jared replies.
Dr. Jones asks, “What could I have done to help you?”
“Well, I would have liked to have at least tried more than irrigating. But, I don’t think I prepared the family well enough for the sedation. I thought we would knock the kid out! I think I started out on the wrong foot with the family and it seemed like you took over because they were upset.” (reflective observation)
Dr. Jones stands up and motions for Jared to walk with her to the procedural practice area. “I think part of the issue is that I did not assess your familiarity with the types of sedation we use for pediatric procedures. What I discussed with the family when they were upset is typically how I prepare them for intranasal midazolam use.” (Dr. Jones reflectively observes and initiates abstract conceptualization)
“Yeah, it was useful to be there for that discussion and I used it to model how I spoke to the patient’s family today.” (Concrete experience and active experimentation)
“That’s good to hear,” Dr. Jones replies. “Let’s walk through your approach in a pediatric patient. We can practice the procedure on this practice suture pad. We can discuss how I prepare families for the repair and when it would be appropriate for me to intervene.”
As they walk through laceration repair, Dr. Jones spends 5 minutes reviewing her laceration repair checklist with Jared. (abstract conceptualization)
“I hope that was helpful,” Dr. Jones says as they walk back over to the work area.
“To be honest, at first, I didn’t think I actually needed to review laceration repair, but I see how it can be different in a pediatric patient. I do feel more prepared and am excited to do this one, but understand clearly when you would need to intervene.” Jared replies. (reflective observation)
“Okay, gather your supplies, and come grab me when the nurse has given intranasal midazolam and we can do this laceration together,” Dr. Jones instructs Jared. She hopes that prepping Jared will not only set him up for success, but also make for a better experience for the patient and family. (active experimentation)
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References
1.Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall; 1984.
2. Kolb DA, Boyatzis RE, Mainemelis C . Experiential learning theory: Previous research and new directions. In R. J. Sternberg & L.-f. Zhang (Eds.), The educational psychology series. Perspectives on thinking, learning, and cognitive styles. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 2004: 227-247.
3. Pickles T, Greenaway R. Experiential learning articles + critiques of David Kolb’s theory. Reviewing.co.uk website. http://www.reviewing.co.uk/research/experiential.learning.htm#ixzz5ws8QAc1s. Accessed 17 Aug. 2019.
4. Dewey, J. Experience and Education. New York: Simon and Schuster, 1938.
5. White JA, Anderson P. Learning by internal medicine residents – Differences and similarities of perceptions by residents and faculty. J Gen Intern Med. 1995;10(3):126-132. doi:10.1007/BF02599665
6. Chung PJ, Chung J, Shah MN, Meltzer DO. How do residents learn? The development of practice styles in a residency program. Ambul Pediatr. 2003; 3(4):166-172.
7. Ha CM, Verishagen N. Applying Kolb’s Learning Theory to Library Instruction: An Observational Study. Evid Based Libr Inf Pract. 2015;10(4):186. doi:10.18438/B8S892
8. Healey M, Jenkins A. Kolb’s experiential learning theory and its application in geography in higher education. J Geog. 2000;99(5):185-195. doi:10.1080/00221340008978967
9. Lemke D, Fielder EK, Hsu DC, Doughty CB. Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study. Pediatric Emergency Care; 2019,35(7):480-486. doi: 10.1097/PEC.0000000000000940
10. Kolb DA. Experiential learning: Experience as the source of learning and development Second Edition. Upper Saddle River, NJ: Pearson Education, Inc; 2015.
11. Yardley S, Teunissen PW, Dornan T. Experiential learning: AMEE guide No. 63. Medical Teacher. 2012;34:102-115. doi:10.3109/0142159X.2012.650741
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