Doctoring the Informal Learning Environment

Anne Marie Cunningham is a GP and Clinical Lecturer at Cardiff University, Wales. She authors the blog Wishful thinking in medical education, which she uses to advance thinking about the training of student doctors.

Recently Anne Marie blogged Location and Learning (which I have reproduced here) and she asked me whether or not I consider her central idea an example of an Informal Learning Environment (ILE).

My short answer is “yes and no” – which I will explain – but for the moment please read Anne Marie’s idea for yourself…


In the last few weeks I’ve been thinking about how we can support the learning that takes place when medical students are on placement.

We know that entering wards can be a daunting experience for students. They don’t feel part of a team. They don’t know who everyone is. They don’t understand what is happening. They don’t want to interrupt nurses attending to patients or junior doctors catching up with paperwork at desks. They see other members of the team wandering in and out of the ward but they don’t know what their role is. They don’t recognise the social worker or the pharmacist or the OT. They might not even know what their own role is. They miss out on opportunities to attend meetings and teaching sessions because they don’t know they are happening.

In fact they spend too long waiting around for someone else to turn up to teach them, and on activities that have little educational value. They generally have a haphazard learning experience.

But placements are very rich environments with many unique opportunities to learn. So what can we do?

Imagine instead that before coming to the ward the students had access to a network which let them find the profiles of all the staff who worked on that ward. They could see the timetables for teaching. They could even see what the last students who had been on this placement had seen and learnt. They can select what they would particularly like to gain from the placement, and this will become part of their profile which will also be available to all the staff on the ward.

The network will also contain links to information about initiatives that are happening in the ward to address patient safety and quality improvement. The students can see if there are opportunities for them to get involved in this work and learn about the input their colleagues have had in the past.

When they turn up on the ward the students check in. They can see the profiles of the staff who are working there and when they should be finishing, when they will be on call and what clinics or theatre sessions they will be doing that week. Their calendar updates with activities that are happening that day that they should know about.

The network that they are tapping into is the same one that all the staff in the hospital use to keep themselves up to date. The students can record their learning and their thoughts about how the ward works. Their input is valued by the staff on the ward and their fellow students from other disciplines.

Do you think this will happen soon? Why hasn’t it happened already? And how could patients use this network?

[Source: Location and Learning]

Light bulb

What a wonderful idea!

Given the realities of the workplace for student doctors, shifting the pedagogy – if ever so slightly – from formal to informal sounds long overdue.

I certainly support the idea of staff profiles. If they include the name, photo, role, expertise, work roster and contact details of each staff member, the student can identify the right SME for their problem and avoid wasting precious time on a wild goose chase.

I also support the idea of the student having their own profile, and connecting it to a personal blog. The blog provides the student with a vehicle to express what they hope to gain from their placement, record their experiences, reflect on what they have learned, and even voice what they have struggled with.

Other students could read the blog to find out how their fellow student is faring, and perhaps make a social connection. The administrators and teaching staff could also read the blog to evaluate the student’s experience and remedy any problems.

Using laptop

In addition to profiles and blogs, I would also suggest facilitating an open discussion forum. Unlike a blog (which may or may not be read by others) a discussion forum enables the student to push a question to the crowd, thereby leveraging the collective intelligence of the hospital.

Senior doctors and nurses could participate in the forum to contribute their expert knowledge and lead the students in the right direction. Of course the student can also share their knowledge by answering someone else’s question, and they can learn incidentally by reading the questions and answers of others.

The discussion forum would also be a suitable vehicle for promoting the various initiatives that Anne Marie speaks of, providing reminders about upcoming teaching sessions, advertising project opportunities, and sharing other hospital-related news.

Doctor with iPad

Having said that, I think a big missing piece of this puzzle is a wiki or some other form of bulk content repository.

I would imagine that in a big institution like a hospital, knowledge is distributed everywhere – on scraps of paper, in folders on shelves, on a poster in the canteen, in people’s heads – which makes it really hard to find (especially when you need it). A wiki enables the hospital to centralise that content so that it can be retrieved quickly, easily and on‑the‑job via a mobile device.

I’m salivating over the thought of the kinds of resources it might contain!

Essentially, then, I would base the hospital’s ILE on three core components:

1. Wiki – the first port of call,
2. Discussion forum, the second port of call, and
3. Staff profiles, the third port of call.

Of course I recognise the importance of formal learning too. I’m not suggesting the hospital ditches face-to-face instruction, for example, with 3D animation. On the contrary, I believe formal and informal modes of delivery complement each other. The trick is determining which is best in each situation, and it might involve a combination of both – why not run a face-to-face demonstration and make the animation available in the wiki for future reference?

In the hospital, then, formal teaching sessions remain a core component of the student’s learning environment. They require support resources such as timetables, agendas and follow-ups.

Taking this one step further, the student’s shifts in the ward may also be considered a core component of their learning environment, as they are instances of on-the-job training. They require support resources such as a roster and perhaps an online check-in facility.

So Anne Marie’s wishful-thinking learning network for student doctors could look something like this:

Hypothetical medical learning environment

As you can see, the interface segregates learning from its management.

The former comprises the ILE (wiki, discussion forum and staff profiles) plus elements of the FLE (work shifts and face-to-face teaching sessions). This zone is where the student goes to learn something.

The latter zone comprises the remaining components of the FLE. This is where the student attends to administrative matters (calendar, floor maps, 60-day checklist), assessment (quizzes, assignments, due dates, grades) and performance management (PMA, development plan, 360° feedback, performance appraisal, manager’s reports).


As an organisation shifts its pedagogy towards the informal end of the learning continuum, its ILE and FLE increasingly represent the distinction between the act of learning and its management.

However, organisations are rarely so extreme in their learning model, and some (like hospitals) probably never will be because formal instruction is so crucial.

So I see nothing wrong with “doctoring” the ILE by associating it with formal elements. ILEs and FLEs are flexible concepts that should be manipulated according to the contexts in which they will be used.

Doctor with iPad

I know if I were a student doctor, I would completely immerse myself in this learning environment. I would get myself an iPad and carry it with me at all times as an indispensable learning aid.

I would check in every day. I would look up what was going on. I would attend teaching sessions. I would search content. I would browse. I would post queries. I would discuss. I would contact SMEs. I would blog. I would read other people’s blogs. I would check out my fellow students’ profiles and perhaps meet up for lunch.

The more I think about it, the more I am convinced this idea is bigger than any individual hospital. It is something the Health Department should implement across the sector. Now.

8 thoughts on “Doctoring the Informal Learning Environment

  1. Hello Ryan,
    Thanks a million for taking the time to think this through. I’m glad I issued you with the challenge! One thing I’d like to clarify is where you position electronic resources such as the 3d animation. Isn’t this formal rather than informal as it is something planned?
    Seperating learning from its management…. that is the challenge. Currently we use Blackboard within our medical school. I’m not sure where it fits into this model at all.
    I hope we can get lots of feedback from others. Thanks again,

  2. The ideas above, Anne Marie’s and Ryan’s combined vision, is to be lauded and accelerated – I wish I knew what the two of you eat for breakfast, b/c I need some!

    If I may offer some thoughts on the barriers to such a model – perhaps we can try to solve them together…

    Technology for Learning – it exists and may be ubiquitous in 15 years, but recent data suggest that social learning and the medical professional are in the ‘top of the first inning’ w/ less than 10% of docs using open-loop systems like twitter and linkedin. We need better case studies of closed-loop systems like Mayo’s and Keiser’s…this is fundamental to the success of the Cunningham-Tracey ILE Training Model ;-)

    Culture of Learning – …is in the eye of the beholder. Beyond generational issues central to senior docs training junior docs, there is still a general culture of hierarchy and the on-going challenges with prioritizing training vs patient care in medicine. It will be interesting to conceive incentivization schemas for mentoring in more informal ways. Again, successfully reengineering the training/learning culture in medicine will be fundamental to the success of the Cunningham-Tracey ILE Training Model

    For example, I believe the best rated teachers w/i the rotation system are the ‘caring, mentoring practitioners’…firm, but comforting…challenging, but rewarding. How will this translate in a tech-enabled ILE? Will the competencies of the best teachers change…and how will we reward this?

    What happens when ‘caring’ fails to come across via technology? What happens when ‘challenging’ fails to come across too?

    We need a mindmap of pilots of success and barriers to address and maybe it is time for a Quora topic…

  3. Really interesting thoughts. Primary and secondary care teaching has very different challenges. Producing an eight week programme as a GP trainee for medical students allowed much more structured teaching than is often possible in a busy hospital. It is often still thought of as a time where it’s a little pot luck. I wonder if a yammer style SM network where doctors post in the community interesting teaching sessions they are organising or learning opportunities on their wards would help create more valuable learning experiences

  4. Hi Ryan
    Nice follow up post to Anne Marie’s original one. I had a meeting today with our NHS QA lead to look at what we might try and do to address some of these issues. We’ve been piloting WordPress to support our online teaching and this has been helping to increase the visibility of key teaching staff and also informing students when various clinics are being held. On our child health block we created an interactive version of our usual Word doc study guides, again introducing key staff on the attachment, learning opportunities, learning objectives etc. This has gone down well with students and most recently we’ve just started using Twitter to let students on the block know who’s taking clinics and to highlight learning opportunities. One of the consultants has also set up a shared calendar so all the students can see when all the various clinics are taking place.
    We’ll be discussing some other ideas over the next few weeks and hopefully start to put some of these into action. When we do I’ll try and remember to blog about what we do.

  5. Cheers Anne Marie.

    This points to the definition of informal learning, which I think is highly dependent on your point of view. Taking the 3D animation as an example, I’d be inclined to consider it an informal learning resource if it were available to the student at their convenience; they can view it when they want, and even *if* they want.

    If, however, an instructor requires the student to view the animation, then I would consider it a formal learning resource. (The student is now dancing to the beat of someone else’s drum.) Of course it’s the same resource, but how it is being used is different.

    But as I say, that’s just my opinion. I’m sure there are plenty of competing views out there!

    I haven’t seen Blackboard for some years now, but from what I remember I don’t see why it couldn’t host the learning environment – or at least provide an interface. I remember Bb arranged its content via a vertical menu down the left-hand side. I don’t know if you can customise those buttons… if you can, then you could easily have a button each for Shifts, Sessions, Wiki etc. I don’t know if Bb has a wiki capability… if it doesn’t, you could simply link to another platform.

    Back in the day I preferred how WebCT structured it’s content, with big chunky icons on the homepage. Somehow I found it more learner centered.

  6. Thanks so much for the feedback, Brian.

    The “Cunningham-Tracey ILE Training Model” – I like the sound of that! ;0)

    Technology for Learning – Yes, you may be right regarding closed-loop systems. Something sponsored and managed at the top sounds like the way to go. Perhaps each hospital can open a separate account on a common platform, which perhaps connects to common resources (eg sector-wide wiki)?

    Culture of Learning – This is the secret sauce. Any shift towards informal learning requires the right attitude and motivation not only from the student, but also from the student’s superiors and peers. I wasn’t aware of the on-going challenges with prioritising training vs patient care; it occurs to me that an ILE might release some of the pressure from that conflict? (This has got Activity Theory written all over it.)

    The irony of these kinds of technology-enabled solutions is that they are contingent on the human factor. Yes, an ILE can fill a gaping void, but that is only one piece of the puzzle. It is no substitute for expert guidance, caring and support; rather it complements it.

    Please post it to Quora…!

  7. Cheers Mathena.

    I’m gathering that hospitals are too busy to train their staff. A slippery slope indeed. It reminds me of that quote… “Q: What happens if you train your people and they leave?” “A: What happens if you don’t train them and they stay?” This challenge is certainly not confined to hospitals.

    I think using Yammer is a good idea. It is a closed system that can fulfil the “discussion forum” component of the learning environment. I agree that the visibility and collaboration generated on this platform would help create more valuable learning experiences.

  8. Natalie, that sounds fantastic.

    I love WordPress. By design it can be used as a blog or message board, but another idea I’ve been toying with is using it as a wiki; it facilitates tagging, categorising, search etc. Food for thought.

    I also love Twitter, but I think its big mistake has been not to offer corporate accounts. Hence for internal purposes I prefer an alternative (closed) platform like Yammer. I see you’ve been thinking along similar lines:

    I’m very keen to read your post-action blogs.

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