Education according to Socrates is the “lighting of a flame and not the filling of a vessel”. We need to ignite the sparks in our students to help them achieve their potential. Not drown them with facts so that they lose all sense of purpose. The American philosopher and educationalist John Dewey (1916) and the psychologist Donald Schon (1987) describe education as the ‘reorganization of experience’. In whatever we do, we may not get what we want, but we will always gain experience. Kolb (2014) also emphasizes knowledge is created through the transformation of experience.

Mark Smith (2015) discusses the work of John Dewey (1916) who felt that the object and reward of learning is “continued capacity for growth”. Education, for him entailed the continuous “reconstruction or reorganization of experience which adds to the meaning of experience, and directs the course of subsequent experience”. "The nature of experience is distinctly human, and education is an emancipation and enlargement of experience" (Smith, 2015).

Education has other properties. The power to extend our abilities, compensate us for certain frailties and in born weaknesses. Education is also therapeutic. It can confront, challenge, stretch, guide, exhort and console us, thereby enabling us to become better versions of ourselves, and in so doing, have a direct impact on the care of our patients and their outcome (Sandhu, 2019).

Smith (2015) further defines education as:

• "Deliberate and hopeful and a belief that people can ‘be more’.
• Informed, respectful, wise and full of possibilities.
• Grounded in a belief that all may flourish and share in life."

Education is also the process of facilitating learning, success and invaluably learners can educate themselves. Education resides not only in academia but in the real world of experience which prepares students for their careers (Dewey, 1933).

Everyone must receive education that helps one think. The quantity of information, education and knowledge imparted to students determines the scope and challenges of education. Learning can be impaired through poor educational practices that marginalize student development (Smith, 2015).

Many still think education is something that goes on only in classrooms. Paulo Freire (1972) described how we make deposits of knowledge as we develop and used the term ‘banking’.

Healthcare students early in their career, are excited and encouraged to study with increasing depth from a curriculum that is extensive, and challenging. Equally important for them are the critical life skills such as being truthful, sincere, team working, communication skills, time management and problem solving in a world of complexity, chaos and uncertainty (Sandhu, 2019).

Faculty have an important role in developing students socially, emotionally, cognitively and academically. Other skills that they need to develop include goal setting, logical thinking and sensible decision making. One of the most important life skills that education teaches us is dealing with failure and developing resilience. The acquisition of such life skills in a supportive environment enhances learning, as students feel valued, and this encourages them to be independent and learn from their mistakes. To achieve the above, students need to develop a growth mind-set and avoid a fixed mind-set by becoming self-directed learners through critical thinking by:

• Reflecting on their learning needs.
• Determine, analyse, and synthesise relevant information.
• Appraise the credibility of information (Dweck, 2007).

Without trusting relationships between students and faculty, the learning environment is poor. This is reflected in subsidiarity "which holds that human affairs are best handled at the lowest possible level, closest to those affected” and in this case it is between the student and the teacher (Smith, 2015). Understanding an experience is not enough. What action should that understanding lead to is the real worth of education. For that students and faculty need commitment.

Education has another virtue, that of hope. No matter what the circumstances, learning and acquiring knowledge is possible (Hooks, 1994). Hope is a feeling of trust and a positive expectation that something good will happen. "An education that leaves a child without hope is an education that has failed" (Warnock, 1986; Smith 2015).

Education has a role in encouraging learning from adverse events; developing leadership at the ground level; governance of policies which are put into practice and health inequity (Sandhu, 2014).

Harden and Laidlaw’s analysis of the 8 roles of a medical teacher (2017) helps us to understand the professionalism involved in being an educator. These are:

Information provider, Facilitator, Resource developer, Role model, Scholar, Curriculum manager, Assessor and Planner. The paradigm of education is explored below through education concepts so that medical teaching can improve student’s learning, and help them to achieve self-actualization.

Learning

Learning is both a process and an outcome and involves cognitive, emotional and communal activity (Illeris, 2002; Smith 2015). It is more than an increase in knowledge, skills or memorising. It is also about making sense of, interpreting and understanding reality (Smith, 2015).These include the values of being truthful and ethical as they motivate, define and colour all of a health professional’s activities leading to critical decision making and actions. These need to be nurtured in an education programme by creating a supportive environment and fostering relationships for deep learning, rather than trying to drill knowledge into people (Smith, 2015). Learning is not something done to students. It is something that they do for themselves.

Lindsay Portnoy (2019), argues “students become attentive, curious and passionate about learning when they can see its relevance to their lives, when they’re empowered to use that learning to solve problems. Students need to consider now that I have learnt it, what am I going to do with it”.

This process of enquiry, discovery, design and reflection needs to be scaffolded for formative assessment. Such a scaffold can consist of:

• Making the content relevant so that students can problem solve the issues they face.
• Isolate or prioritize the concerns.
• Communicate ideas and provide valid reasoning.
• Prototype a solution and test it.
• Revise the design for maximum impact and reflect on the process.

Reflection allows us to be conscious that learning is happening. Educators may have clarity of the learning outcomes and how this fits into the curriculum. But working with students, what develops is the interaction and dialogue of the hidden curriculum. This sort of learning works largely through conversation and can take unpredictable turns. Students are taught formally and informally to expedite their learning and to change their behavior.

To achieve this the learning environment and relationships are important. Laurillard (2012) defines how students learn and six learning types:

Learning types

1. “Acquisition – Listening to a presentation or podcast, reading from books or websites and watching demonstrations or videos
2. Discussion – Expressing ideas, questions, challenges and responses to ideas and questions from faculty and other students.
3. Inquiry – Exploring, comparing, critiquing resources that reflect the concepts and ideas being taught.
4. Practice – Adapting their actions to the task goal, and using feedback to improve their next action to achieve the goal.
5. Collaboration – Using discussion, practice and production to create a shared output that uses their knowledge and inquiry.
6. Production – Expressing what they learned as their current conceptual understanding and how they used it in practice”.

Having and Being

Learning is part of 'having' and 'being' concepts. Students in the 'having' mode hold onto what they have ‘learnt’. They are not creative or innovative. Those who engage by listening, and through a cognition process become active through critical thinking are in the 'being' mode (Fromm, 1979).

Learnification

Biesta (2013), argues against education to become stronger, more secure, more predictable, and risk free. He regrets current standardized testing and measurement trends as defects to overcome. Education for him is a practice that is slow, difficult, insecure, unpredictable, full of risks and uncertainties. Furthermore, he describes a phenomenological distinction between ‘learning from’ and ‘being taught by’. Learning from a teacher means, that the teacher is a resource used by students to gain access to what they want to know or learn to do. Being taught by means, ‘someone showed us something or made us realize something that really entered our being from the outside’. This understanding is important for students to become independent critical thinkers.

Critical Thinking

The heartbeat of critical thinking is the longing to know – to understand how life works (Hooks, 2010). Students are born and organically predisposed as critical thinkers. Unfortunately, this passion for thinking can end when they are educated to conform and obey. Students then dread thinking for themselves and assume what they need to do is to consume information, and regurgitate it at appropriate moments. To be a critical thinker, you need to embrace the joy and power of thinking itself and have the capacity to determine what is significant (Hooks, 2010).

Critical thinking consists of seeing both sides of an issue, being open to new evidence and ideas, reasoning dispassionately, demanding that claims be backed by evidence, deducing and inferring conclusions from available facts and solving problems (Willingham, 2010).

Therefore, critical thinking involves exploring the who, what, when, where, and how of things. Then making sense of the answers and prioritizing their impact.

Critical thinkers are clear as to the purpose at hand and question information, conclusions and points of view. They strive to be clear, accurate, precise, and relevant. They seek to think beneath the surface, to be logical and fair. All these explanations involve an understanding and judgement.

The default position of students is that they resist critical thinking and are comfortable with learning that allows them to remain passive. Critical thinking requires students to be engaged. Keep an open mind and a willingness to acknowledge that we do not know (Hooks, 2010).

Critical thinking in health sciences can be introduced through critiquing reports and data, interpreting information and learning to draw conclusions, making judgements and prioritising decisions, self-directed learning and academic writing (Barnet and Bedau, 2013).

Educators need to be aware of the cognitive theories of learning including dual processing theory (Gawronski and Creighton, 2013). Cognitive learning theories unlike behavioural theories are concerned with perception and the processing of information (Taylor and Hamdy, 2013). Cognitivism defines learning as a more complex and a higher order skill activity. Changes in behaviour are observed, but only as an indication of what is occurring in the brain. The mind is like a computer. These theories suggest that an integrated approach to education can have important benefits for learning and retention, because it leads to applying knowledge through clinical reasoning.

Cognitive Integration

Students often raise concerns that the clinical relevance of much of the basic science content was not clear, and they could not see the relevance of the information taught and the patient’s illness.

Cognitive integration allows the integration and relevance of basic sciences to clinical science which is essential for curriculum planners. Curriculum development should ensure that the content is logical, relevant with clear linkages for learners.

A simple approach for instance in curriculum development can consist of:

1. Do a needs assessment
2. Set goals and objectives
3. Develop educational strategies
4. Implement the strategic plans
5. Evaluate the outcome and study the feedback

Dual Processing Theory (DPT)

An understanding of DPT can allow us to discern how reasoning processes and knowledge base structures work together to perform tasks. This can support educators in better teaching and assessment of competencies. DPT indicates that our ability to process information happens through two distinct systems (Gawronski and Creighton, 2013).

System 1 is an implicit, automatic, unconscious process which is fast thinking, effortless and involves feelings and emotions and is largely unconscious. System 2 is an explicit, controlled, conscious process which is slow thinking, effortful and requires a rational conscious deliberation. We spend most of our time with System 1 dealing with impressions, intuitions, impulses and feelings. System 2 can override or modify the response of System 1 through our understanding of beliefs and voluntary actions. But this takes effort and is not always indulged in making the default mode to accept System 1. Students initially learn through System 1, but deep learning occurs through rational analysis of experience in System 2 (Gawronski and Creighton, 2013).

Reflection

Education and critical thinking involves purposeful reflection. This leads to the critical analysis of knowledge and experience, enhancing meaning and understanding, resulting in increasing empathy, communication skills, enhanced learning, greater insight into experiences and promotion of evidence based practice. Where there is social and cognitive congruence including relevance, it helps to make them more relatable and understandable.

Freire (1972) described this as praxis. As educators, we create and sustain our educational goals by (Smith, 2015):

• Reflecting on experiences as learning requires concrete space.
• Attend and connect to feelings.
• Understandings leads to development of conceptual frameworks.
• Commit. Commitment is concerned with developing and prioritising actions.

Competence

Competence in health sciences education is the efficacious and efficient use of knowledge, skills resulting in sound clinical reasoning. Educational competence is a journey of lifelong learning in which reflection and assessment helps students to recognise and implement their learning needs. The notion of quality is transformational. Such transformation enables students to be emotionally stable, increase their self-confidence and enhance their critical thinking. The students raise their self-awareness, transcend prejudices and acquire knowledge, skills and behaviours to increase their career opportunities.

Where such an educational transformational culture does not exist, it leads to academic mediocrity and stifled innovation, thus negatively impacting on institutional quality and efficiency (Sandhu, 2019; Gill and Singh, 2019). Proclivity for hard work and innovation is required to deal with wicked problems, complexity, chaos and uncertainty (Sandhu, 2019).

Students are stressed with information overload of over 60,000 diagnoses and 6,000 interventions (Harden, 2018). The curriculum is limited and can’t cover everything. Furthermore, although the curriculum has expanded significantly the time to deliver it has remained much the same. An end point is not defined.

When teachers bring their passions about learning and about life into their teaching, they disperse the fog of passivity, and energize their students (Fried, 2001).

Faculty often discuss how to lecture or run an OSCE station and so on. These are the tools of teaching. The question is how will this make a difference to the education of the students? The answers will affect learners meeting their needs, and move away from faculty simply being a source or provider of information (Harden, 2018). There can be a dissonance between the institution and the teacher’s purpose. A teacher may see their role as provision of knowledge and information. The institution may see the role of the teacher as a facilitator of learning, supporting the student on a personal learning journey. The cognition of learning and competence above has led to competency based medical education.

Competency based medical education (CBME)

Traditional curricula are based on being subject – centred and time based. There is inadequate feedback as most evaluations are summative. The emphasis is on accruing knowledge and ignores skills, attitudes and behaviours in dealing with patients and colleagues. Graduates may be knowledgeable but lack the soft skills of communication, team working, inter-professional collaboration, patient relationships, ethics and professionalism.

Competency is defined as “the ability to do something successfully and efficiently”. CBME addresses the skills graduates need to fulfil their professional role to become a doctor (Harden and Laidlaw, 2017). It is adaptive education that is flexible and against one size fits all. Time based training is de-emphasized with accountability for the student’s learning requirements. The teaching, learning and frequent formative assessments should ensure the students acquire the competencies as part of the training process. Student assessments are individualised and based on objective measurable standards. The experiential learning is close to realistic healthcare practice (Harden, 2018; Jason, 2018).

FAIR principles. (Harden and Laidlaw, 2013)

In recent years with the development of outcome based education where content is based on the learning outcomes, the FAIR principles have gained prominence. These consist of:

Feedback: Give regular feedback to students’ performance against the learning outcomes.

Activity: Achieve deep learning through active rather than passive learning.

Individualization: The learning should meet the students’ professional requirements.

Relevance: The learning must be relevant to the student’s personal needs and career objectives.

Respect and Wisdom

The values of health sciences education involve being respectful, informed and has the virtues of truth and wisdom. It develops into a positive outlook of how to interact with colleagues and patients.

The moral worth or value of ideas and relationships is important through respect and sincerity (Williams, 2002). Wisdom is different from being scholarly or learned. Wisdom entails in education terms:

• Understanding purposeful self-fulfilment.
• Following the path of self-development with sincerity.
• Experiential learning.
• Realising who we are, the systems we are part of and how we all gel together with a unifying purpose.
• Acquire critical thinking and self-actualization.

All the above defines the health sciences educators who need to be aware of the stress students face. Educators need to create a better learning environment through understanding emotional intelligence and impart resilience.

Burnout

Stress and burnout is a serious issue in students, and linked to adverse elements in the learning environment (Slavin, 2016). Hopelessness, despair and exhaustion are common symptoms in those struggling to come to terms with being away from home and friends and facing an arduous curriculum. Higher Education Institutions unfortunately seem to value competition over nurturing and nobody is supposed to make mistakes. This can lead to a problematic mind set where students see their identity linked to performance. Poor performance can lead to self-blame, de-personalization, feelings of inadequacy, embarrassment, shame, maladaptive perfectionism and worse, a stigma around seeking help with mental health problems. 

Educators can help to improve the learning environment by (Slavin, 2016):

• Instituting helpful curriculum organizational interventions to optimize the learning environment. The curriculum should be seamless and deliverable in a reasonable time, and not be overburdened.
• Strive to create an atmosphere of respect and engagement that helps students to build social relationships and a sense of a community.
• Teach students resilience through self-awareness, stress management and emotional intelligence.
• Understand the importance of self–care, mental health and sharing of problems.

Regular feedback through more formative rather than summative assessment will help students to understand the relevance of their study, and why the knowledge and skills acquired are essential for good patient care.

The USMLE Step 1 examination marks are a powerful discriminator and often correlates with entry into residency programs. This stress drives the students and medical schools into a disproportionate energy regurgitating health sciences to secure higher marks. Since 2010, there is more pressure as the number of US medical school matriculants has increased by 23%, while residency slots haven’t kept pace (AAMC.org. News-insights, Weiner, S. (2019); USMLE.org. InCUS. (2019). The recent announcement that from 2022 the Step 1 examination will be a pass and fail examination is to be welcomed, and students can be judged on a broader category of excellence. A current huge problem remains, regarding the cost of healthcare education and the resultant student debt (Pisaniello et al., 2019).

Emotional Intelligence (EI)

Stress is helped by understanding EI which is the ability to understand and regulate one’s emotions and the emotions of others. EI improves academic achievement, health and well-being as well as career performance. Properties such as decision making, empathy, memory, perception and learning makes an impact on the emotions in dealing with patients and colleagues (Goleman, Boyatzis and Mckee, 2008). EI allows physicians mindful and empathetic communication, earn their patient’s trust, and encourage self-efficacy and patient autonomy.

Resilience

Stress from health, family and relationship problems, work and financial worries require the individual to develop resilience to cope with such difficulties. This requires rational problem solving skills. If students are less resilient they are more likely to dwell on problems, feel overwhelmed, use unhealthy coping tactics such as drugs and alcohol to handle stress, and develop anxiety and depression (Slavin, 2016).

Resilience skill sets and approaches are summarised below:

1. Mindful of what is going on and why.
2. Being rational in the approach to problem solve.
3. Seeking help and knowing when and who to ask for help.
4. Maintaining mental and physical health to cope with the challenges.

Practical plans to embed resilience as developed by University of Pennsylvania, Positive Psychology Center with their Penn Resilience Program and PERMA™ workshops are:

• “The capacity to make realistic plans and take steps to carry them out.
• A positive view of yourself and confidence in your strengths and abilities.
• Skills in communication and problem solving.
• The capacity to manage strong feelings and impulses”.

In an arduous career such as medicine, faculty need to be cognisant and develop resilience in their students.

Ultimately students have to learn to go through the threshold of deep learning to develop themselves as discussed above. This is self-actualization which is the realization or fulfilment of one’s talents and potentialities. This requires an understanding of how to develop and survive and achieve the personal goals in life. This personal growth drive happens throughout life (Hooks, 2010).

Teachers are concerned that their students acquire a ‘good education’ which doesn’t just deal with knowledge but applied knowledge to support them in their careers, but also nurtures within them an ongoing, life-long commitment for self-development and social justice to fulfil their potential.

A teacher who humiliates their students by exercizing their authoritarian power, will crush the students’ spirits and dehumanize their minds and bodies. Nurture the self-development and self-actualization of students (Hooks, 2010).

Transcendence

Pedagogy is the method and practice of teaching and adds something new of value in student’s learning (Biesta, 2013).

Alterity, or the state of being different has a meaning in education in the course of the maieutic model of Socrates. Here learning occurs by going through a threshold of learning within the ‘I’ provoked by the other (Newcombe, 2005).

In health sciences’ education the concept of not getting the right answer first time or not at all, or the teacher maybe wrong is difficult for students. Being smart is not enough. It is about team working, communication skills and empathy. Sometimes there isn’t a right answer!

New learning entails letting go, because a previous skill or knowledge has to be abandoned as the learner gains new understanding or skill. Thus going through the threshold concepts is important for students to grasp the future.

Threshold Concepts

Land, Meyer and Smith (2008) describe threshold concepts as concerned with encountering the unknown, undertaking a journey of discovery of new knowledge. The scholarly new understanding gets transformed into how people think, perceive or apprehend new learning or phenomena.

Characteristics of a threshold concept as described by Land, Meyer and Smith (2008) are:

• “Integrative – once learned brings things together.
• Transformative – once understood changes the way students think.
• Irreversible – they are difficult to unlearn.
• Bounded – delineate a conceptual space serving a specific and limited purpose.
• Re-constitutive – entail a shift in learner subjectivity.
• Discursive – crossing of a threshold will incorporate an enhanced use of language.
• Troublesome Knowledge - can be troublesome when it is counter-intuitive, alien or seemingly incoherent”.

Liminality

Liminality is another threshold concept which affects how we behave and think in education (Turner, 2008). Liminality means on the threshold of something, relating to an initial stage of a process as in rituals associated with birth and death. All experience some discomfort when they do not grasp the context of a new circumstance.

In educational terms there is a need to lead students over the threshold and make them understand the new situation or ideas. The progressive function of the liminal state according to Meyer and Land (2006) can involve:

• “Countenancing and integration of something new.
• Recognition of shortcoming of existing view.
• Letting go of the older prevailing view.
• Letting go of an earlier mode of their subjectivity.
• Envisaging and accepting an alternative version of self through the threshold space as a practitioner.
• Acquiring and using new forms of written and spoken discourse and internalizing these”.

Negative liminality refers to those who fall through the cracks – the suicides and the hopeless. Bullying in the workplace and in education are also examples of this (Meyer and Land, 2006). 

Troublesome knowledge

Troublesome knowledge mentioned above has its own baggage and Perkins (2006) describes the following domains:

• “Ritual knowledge.
• Inert knowledge.
• Conceptually difficult knowledge.
• The defended learner.
• Alien knowledge.
• Tacit knowledge.
• Loaded knowledge.
• Troublesome knowledge”.

In healthcare education troublesome knowledge is intimately linked with clinical practice. This produces its own paradox in dealing with the uncertainty of professional practice. Clinicians often act confidently in patient management, when they do not understand the underlying cause of the problem. Expert practice produces this paradox of acting with confidence, while being uncertain. This concept defines another property of education which enables teachers to work with ill-defined challenges while feeling uncertain (Ilgen et al., 2019; Barnett, 2014). 

Safe Places

Students need safe places (Stengel and Weems, 2010). These are pedagogical conditions under which students can be free from self-doubt, hostility, fear or non–affirmation. The zone of proximal development of the constructivist Vygotsky (Taylor and Hamdy, 2013) is a key area where safe places can be nurtured.

Transformational Education

The above concepts can be summarised through transformational education. R H Harden (2018), Hilliard Jason (2018) and Hossam Hamdy (2018), make the following observations regarding current transformation in medical education:

• Health science education is continuous with the healthcare system of the country and its economic, social, political and cultural systems.
• Healthcare is a social science. It is all about people, societies, human interaction and communication.
• Recognising that critical analysis is essential for synthesis of information to make decisions.
• Faculty role is changing from information provider to facilitator of learning, role model, innovator of learning approaches.
• Use of technology and simulation (Han, Resch and Kovach, 2013). This has had a big impact for instance how anatomy is taught using 3D anatomage tables (Anatomage Inc. Virtual dissection table 3 D). Students are trained on simulation models prior to treating patients to ensure their safety.
• Increased small group learning in various guises be it problem based learning or team based learning. The students learn the practical activity of problem solving through team work, communication skills and respect for each other. They move away from individual learning of a lecture theatre to collaborative learning so that individual students have a voice.
• Understanding cognitive theory. Health sciences education needs to be grounded in sound cognitive theory for effective pedagogy.
• Curricula are no longer set in stone, but innovative and appreciate the demands from learners and the impact of the information explosion. New knowledge means that irrelevant subjects have to be released.
• Unnecessary focus on foundational science shifted to patient centered care, behavioral science, interdisciplinary team work, technology and big data to provide evidence based practice (Hamdy, 2018).
• Medical training focused on 1% of inpatient care, ignored primary care, chronic disease management, rehabilitation, palliative care, wellness and prevention. Early exposure to patients is essential for the relevance of healthcare education (Hamdy, 2018).
• Greater emphasis on soft skills. Qualities such as team and inter-professional working, communication skills, empathy, sincerity are the foundation of developing the healthcare workforce. Senior students make excellent role models for junior students through peer support PALS group, and international citizen awards. 

Medical education in its broadest sense becomes co-responsible for shaping future professional practice, as many healthcare practitioners and scientists become educators. Faculty development for them is essential to address the needs of healthcare education such as curricula development (Harden, 2018). Important iterative questions to consider are what should we expand on, what should we stop and what should we keep as the status quo. Ultimately we need to make health sciences education better and not just different.

An adequate University changes what you know, but a great University changes who you are and how you behave (Wilkes, Cassel and Klau, 2018).

“We are currently preparing students for jobs that don’t yet exist … using technologies that haven’t yet been invented … in order to solve problems we don’t even know are problems yet”. Andreas Schleicher, Director for education and skills, OECD (Jason, 2018).