Exploration Before Explanation: Embracing Errors to Develop Adaptive Expertise

By Leonardo Aliaga (@BolivianLeo)

Adaptive expertise is the ability to transfer existing skills and knowledge to solve novel problems.¹ Transfer is the currency of adaptive expertise. Achieving transfer depends on “seeing” a topic’s underlying structure.² Making mistakes when learning helps you “see” that underlying structure.

Why Do We Need Adaptive Expertise?

Physicians are guaranteed to encounter novel clinical situations in future practice since it is impossible for them to experience every permutation of every clinical scenario in residency. Medical errors sometimes occur when physicians manage novel clinical situations they had not previously encountered during training. Adaptive expertise is a skill that enables physicians to effectively manage novel clinical situations not encountered during training.³ However, residency training traditionally focuses on errorless training that hinders the development of adaptive expertise. A paradox results:

Physicians may be at higher risk of committing medical errors during independent practice if they have not committed sufficient errors during training.

How We Typically Teach

Traditional models for delivering educational content largely revolve around didactic sessions that show learners the correct way for approaching and solving problems before they try to solve those problems themselves. Explanation comes before exploration in this model. Learners are encouraged to exhibit errorless performance when practicing a skill or learning to solve a problem. This kind of errorless training is efficient when developing routine expertise, i.e., learning to solve problems whose characteristics or presentation do not vary.^4,5 However, medical education requires a more complex model of training that accounts for the variation encountered when solving clinical problems.

Exploration Before Explanation

A potential solution is Error Management Training, an instructional methodology that improves transfer and develops adaptive expertise by making learners produce errors when solving difficult problems before being shown how to solve them.^6,7 Exploration comes before explanation. Courting errors during learning might appear antithetical to our goal of achieving errorless performance in medicine. However, simply seeing errors in a negative light overlooks the powerful advantage learners gain by making mistakes:

1. Learners use their existing mental representation of a problem when trying to solve it; producing incorrect solutions forces them to confront their faulty or incomplete mental representation.
2. Making mistakes triggers metacognition, allowing learners to view a problem from multiple angles and use their wrong answers as contrasting examples to the correct answer.^8,9
3. This process of contrast and comparison illuminates the qualities that make the correct answer correct. These qualities are the problem’s critical conceptual features, i.e., the components that define a problem’s underlying structure.
4. Errors engineer reflection on a topic’s critical conceptual features which is essential for developing transfer.²
5. Learners refine and improve their existing mental representations of a topic by incorporating these critical conceptual features.
6. By developing a deep conceptual understanding of a topic, learners “see” its underlying structure and become less likely to be fooled by the surface features of new problems.^1,10

This is how errors can help residents gain a deeper conceptual understanding of a topic, which then allows them to transfer those skills and knowledge to novel problems. The ability to transfer is the “substance” of adaptive expertise and enables residents to avoid committing future errors when confronted with novel clinical scenarios.

The Hidden Connection

Error Management Training capitalizes on several strategies essential for developing transfer and ultimately adaptive expertise, captured in the points above. Purposely incorporating errors into training creates productive struggle where learners question their assumptions for solving a problem.¹¹ This desirable difficulty emphasizes conceptual understanding over rote performance and triggers the metacognition needed for adaptive expertise.^7,12  Producing incorrect solutions provides contrasting examples to the correct solution; this kind of meaningful variation is another key method of developing adaptive expertise.¹³  Error Management Training harnesses the hidden connection between errors and adaptive expertise. We gain a unique advantage over traditional errorless training by specifically targeting the cognitive activities that develop adaptive expertise.

Embracing Errors

We can reduce preventable medical errors by developing physicians’ adaptive expertise. To achieve this goal, we must reframe how we view errors in residency training. Traditional models of errorless training inadvertently rob learners of opportunities to engage in reflection and gain a deep, conceptual understanding of the topic being learned.¹⁰ Didactic explanations can never be as rich as the variety of clinical scenarios we encounter; adaptive expertise addresses this problem. Embracing errors during training in order to develop adaptive expertise will ultimately help our residents reduce errors during unsupervised practice.

About the author: Leonardo Aliaga, MD is a medical education scholarship fellow and emergency physician in the Department of Emergency Medicine at Stanford School of Medicine. Twitter: @BolivianLeo

About the editor: Michael A. Gisondi, MDis an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael currently holds a position as Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University. Twitter: @MikeGisondi

References

1.  Branzetti J, Gisondi MA, Hopson LR, Regan L. Adaptive expertise: The optimal outcome of emergency medicine training. AEM Education and Training. 2022;6(2).

2. Kapur M. Examining Productive Failure, Productive Success, Unproductive Failure, and Unproductive Success in Learning. Educational Psychologist. 2016;51(2):289-299.

3. Royce CS, Hayes MM, Schwartzstein RM. Teaching Critical Thinking: A Case for Instruction in Cognitive Biases to Reduce Diagnostic Errors and Improve Patient Safety. Academic Medicine. 2019;94(2):187-194.

4.  Hatano G, Inagaki K. Two courses of expertise. In: Child Development and Education in Japan. A series of books in psychology. W H Freeman/Times Books/ Henry Holt & Co; 1986:262-272.

5. Pusic MV, Santen SA, Dekhtyar M, et al. Learning to balance efficiency and innovation for optimal adaptive expertise. Medical Teacher. 2018;40(8):820-827.

6. Dyre L, Tabor A, Ringsted C, Tolsgaard MG. Imperfect practice makes perfect: error management training improves transfer of learning. Med Educ. 2017;51(2):196-206.

7. Keith N, Frese M. Self-Regulation in Error Management Training: Emotion Control and Metacognition as Mediators of Performance Effects. Journal of Applied Psychology. 2005;90(4):677-691.

8. Soderstrom NC, Bjork RA. Learning Versus Performance: An Integrative Review. Perspect Psychol Sci. 2015;10(2):176-199.

9. Metcalfe J. Learning from Errors. Annu Rev Psychol. 2017;68(1):465-489.

10. Eva KW. Diagnostic error in medical education: where wrongs can make rights. Adv in Health Sci Educ. 2009;14(S1):71-81.

11. Mylopoulos M, Steenhof N, Kaushal A, Woods NN. Twelve tips for designing curricula that support the development of adaptive expertise. Medical Teacher. 2018;40(8):850-854.

12. Kua J, Lim WS, Teo W, Edwards RA. A scoping review of adaptive expertise in education. Medical Teacher. 2021;43(3):347-355.

13. Mylopoulos M, Kulasegaram K, Woods NN. Developing the experts we need: Fostering adaptive expertise through education. J Eval Clin Pract. 2018;24(3):674-677.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The Royal College of Physicians and Surgeons of Canada. For more details on our site disclaimers, please see our ‘About’ page

Picture Source: Pexels