Much hasbeensaidaboutlearningofstudentsorlearningofdoctors in mentorshiprelations. => littleisknownabouthowdoctorslearn in day-today => ephemeralandlooselycoupled .. withveryimplicitedcuationalstructurs
First discussprocessesassociatedwiththeseroles, theirinterplayandhowdoctors link thistoreflectionand mental concepts) => Zoom inSecond, howtheserolesareaffectedbytheinterplayofvariouscontextualfactors => Zoom out
1. Disentangling the dynamics of learningin clinical contextsChristoph Pimmer and Norbert Pachler, UCL: 2nd Medical Education Conference
2. Overview Perspectives on and conditions for learning Dynamics of learning and teaching processes Interplay of contextual influencing factors Cognition between external and internal representations and directions for future research
3. Perspectives on learning learning as  a process of ‘coming to know’ and ‘being able to operate successfully in and across’ new and ever changing contexts and learning spaces  a process of meaning-making through successful communication  an augmentation of inner, conceptual and outer, semiotic resources  a transformational engagement and purposive work with cultural resources in line with learners’ interest and personal definition of relevanceKress and Pachler, 2007
4. Conditions for learning• interaction with others such as peers and experts in pairs, teams, or communities through different forms of external dialogue,• interaction with oneself on the individual cognitive and metacognitive level via internal dialogue,• the confrontation between internal and external dialogue including the social relationships that arise as a result of this, and• the interaction between the individuals and others with the learning, training, and social environment in which learning and instruction is taking place, including the environment’s physical, temporal and emotional attributes (i.e., its affordances, constraints, and conventions)Kirschner, 2006
5. Cognitive apprenticeship learning is actively constructed and situated in order to help learners understand the purpose and meanings of knowledge intends to make thinking visible combines traditional apprenticeship approach with cognitive dimensions six elements of providing with an opportunity to observe, engage in and discover expert strategies in context: modelling, coaching, scaffolding, articulation, reflection, explo rationCollins, 1991; Pimmer, Pachler, Gröhbiel & Genewein, 2009;Pimmer, Pachler, Nierle & Genewein, 2012
6. Distributed cognition coming to know not an act of individual cognition alone but instead a process of engaging in the social world and of mediating the sense made of it grounded in life experiences, physical embodiment, sense of rationality, cultural traditions, interaction patterns of communication knowledge as a socially mediated product, never absolute and always subject to questioning, reinterpretation and renegotiationPachler and Daly, 2011; Stahl, 2006
7. Context, study backgroundBackground: larger programme that examined doctor-to-doctorconsultations as well as learning of doctors in emergencydepartments in Switzerland.Methods: 30 semi-structured interviews/ focus groups in fourhospitals; observational studies one site; (inductive) contentanalysis.Focus: learning from the residents’ perspective
8. Three basic roles:Doctor as «ACTOR» (being responsible)Self-directed and autonomous forms of learning and problem solvingDoctor as «PARTICIPANT» (being involved)Participatory learning process; learning by co-operating with moreexperienced doctorsDoctor as «STUDENT» (being taught)Deliberate teaching processes that go beyond the necessities of patienttreatment
9. Dynamics of learning and teaching processes
10. Exploration: learner as actor Clinical/medical reasoning: thinking and decision-making processes with respect to a specific patient case One creates the concept of what the next steps are going to be and what suggestions one wants to put forward. (08) Patient examination and treatment: diagnostic actions such as physical examinations or anamnesis as well as first therapeutic practices Accessing codified knowledge in the form of internet sources, books or medical lexica.
11. Involvement: learner as participant Articulate developed conceptions on the problem and possible solution approaches via phone or face-to-face I think one learns already during the telephone conversation […]. One has to prioritise information, weigh it up, relate it to laboratory values and other examination findings and develop a first synthesis. Taking part (joining experts in patient examination) and observing Listening to experts verbal information on patient-treatment, which is directly addressed to learners; or questions and explanations to patients. Asking focused questions can stimulate teaching processes of experts
12. Teaching: learner as “student” Promoting learners to articulate their understanding of the case by asking challenging questions Verbal explanations: to make underlying reasons explicit (why and how) Physical and gestural demonstrations
13. Learners’ conceptions The exploratory processes are based on the learners mental and embodied conceptions, which were adjusted and (further) elaborated according specific requirements and characteristics of the case (iv). Processes of involvement and teaching then make the experts conceptions explicit and allow learners to contrast those with their own conceptions (xiii). This reflective comparison (xiv) reinforces or changes the learners conceptions. Of special significance is that one has already seen the patient and that one has already formed an opinion before the specialist arrives. It is as if you get a corrected exam back. 
14. Interplay of contextual influencing factors
15. In a consultation the interplay of different contextual influences determines a) the role ofthe learner and b) the quality of the learning
16. Learner: motivation, domain-specific interest and expertiseand experienceMotivation, domain specific interestThe degree of a case’s alignment with the learner’s specialinterests and intended specialisations municati Personal on, attit ity, com Teachin g abiliti ude, Experts   There are some who don’t join the specialist out of principle, to save time. Then there are those who think they can learn something and go along. It depends on how you set priorities. (04)Experience, expertise At the moment I (experienced resident) take the decision in most cases about what the patient needs and what we do. […]. My decisions are reviewed only the next morning by superiors. (01)
17. Expert: personality, communication attitude,and teaching abilitiesPersonality, communication attitude: Experts greatly differed with respect topersonal characteristics, abilities and behaviour There are two types: those, who do it quickly, and those, who like to explain. (06)Teaching abilities: I had an extremely good senior physician. I learnt a lot from him because he asked me questions. For example, he said that we have this case and asked me what my main diagnosis was, and if that’s correct, what was relevant for making a decision, […] He did this systematically and well. That depends very much on the person (17).
18. Organisational/ cultural: hospital (size, scope) and department:culture, rolesHospitals: In smaller hospitals, residents worked and learned Experts  Personal ity, commu nication,more often and more intensively in the role of actors  attitude, Teachin g abiliti Here [in a small hospital] you have a patient and he is yours from head to toe. You examine him, evaluate ECG data, heart, lungs, blood and the fracture. (14)In larger hospitals, doctors learned more in the role of participants/ "students”.Department: role, cultureOrganisation of the roles of on-call doctors varied widely from department todepartment If I were to start tomorrow in thorax surgery, I’d be called in my role as thorax on- call doctor although it is my first day and I have little idea.(06)
19. Situational: patient census (complexity, urgency, patientnumber) and time: day/night/ weekendHigh levels of workload and stressnegatively affected the quality of the residents learning ingeneral and in particular the extent to which doctors learnedas “participants” and “students”. If a lot is happening in emergency, then [explanation] tends to be difficult and the residents are glad, if they can just carry on. (05)Time: day, night, weekendDuring dayshifts, learners easily involved experts and learned as participants. Duringlate and nightshifts and on weekends, learners had to act and decide moreindependently as actors.
20. Learning effects1) Biomedical, clinical andcultural knowledge (learning how we do things here) f a lot is happening in emergency, then it [explanation] tends to be difficult and the assistants are glad, if they can just carry2) Security/confidence: confirmation and irritation I remember best, if something went wrong. It sits like a lump one is alert the next time and focussed. (03)
21. Dynamics of learning in clincal contexts All factors interact differently in every learning situation. Interplay manifests itself in three different roles assumed in highly dynamic ways:  actors  participants  students and in a different quality of learning within these rolesOver time … learning effects accumulate to experience, expertise and domain specific interests doctors learn more and more in the role of actors throughout their careers
22. Distributed cognition – the flow of information across external and internal representations Drawing on the Distributed Cognition Approach
23. Distributed CognitionDistributed cognition (DCog) places centrality on (1) how information is propagated through a system in the form of representations held in media (2) between individuals (e.g., speech, gazes, gestures) or (3) in the physical environment (e.g. tools, computers etc.).Hutchins and colleagues (for example, 2000; 1995a, 2000; 1996)
24. Possible directions for future analysisDrawing and extending on the principles of Distributed Cognition, we suggestthat future research should more closely and thoroughly analyze the interplay of  different multimodal and in particular embodied representations and of  technological work artifacts and their meaning for learning, and thereby “zooming in and out” at the same time.
25. Multimodal, embodied representations Doctors (experts and novices) use bodily actions to interactively build participatory frameworks and to synchronously and asynchronously connect different modal representations: speech, graphical and physical structures of their own bodies and of the environment. Thereby they formed complex, multi- layered and multimodal representations
26. Technological work artifacts and learning?• Ephemerality of representations: clinical artifacts are orientated towards the efficient flow of information through the system …• and to a much lesser extent to substantiate representations over time and, thereby, allow for learning which is based on the documentation, later reflection and sharing of external representations. This morning we had a great picture (X-ray) of a hand, very fine and not at all easy to see what there was. Of course, when the patient is no longer in the system I wont go to search again. […] I showed the picture to those who were there. But I have to say that if I had had it saved Id have shown it to the newcomers as well and would have said: have a look, here …
27. Use of mobile phones for learningIn loosely-coupled, non-routine, "interruption-driven" contexts such as clinical environmentsactors make use of a wide range ofrepresentational resources ininformal, unexpected, unpredictable and ad-hoc ways At the moment it so happens that some simply have a smartphone with them. It is placed on the table and passed around. […] We tend to sit in a U-shape […]. If there is a picture […] on the smartphone, it is passed around in a circle, or at least a semi-circle, all the way to the supervisor, so he can see it. […] The picture is looked at briefly and commented on.
28. Contact Norbert Pachler Christoph Pimmer http://www.norbertpachler.net/  http://www.christoph.pimmer.info www.diigo.com/user/servusuk  https://twitter.com/#!/christophpimmer http://ioe-  www.slideshare.net/ChristophPimmer ac.academia.edu/NorbertPachler  http://fhnw.academia.edu/ChristophPim mer