A qualitative study exploring how students’ conceptualisations of lifelong learning develop in an undergraduate medical training programme

ABSTRACT

There is currently a paucity of evidence regarding how medical undergraduate training influences students’ attitudes and skills for lifelong learning (LL). This study describes medical graduates’ conceptualisations of LL at the University of Dundee and proposes a provisional theory regarding related curriculum influences. Using a methodology informed by scientific realism, semi-structured interviews were employed to explore six graduating medical students’ conceptualisations of and preparedness for LL. Findings were thematically analysed and aligned with existing educational theories. Graduates characterised LL as a continual process which emphases reflection, responsibility for learning, and maintaining motivation. Their conceptualisations did not translate readily beyond professional medical practice. The strongest curriculum influences were experiences in the authentic clinical environment, use of learning portfolios, and the intercalation of a medical science degree. In the absence of formal teaching, medical students’ conceptualisations of LL develop in accordance with both the implicit prevailing professional narrative and from curriculum interventions which: increase their sense of relatedness with their community of practice; provide autonomy in learning; and engender a sense of responsibility to learn. This provisional theory could be valuable in guiding the teaching and assessment of LL in-line with contemporary graduate outcome frameworks.

KEYWORDS:

• Lifelong learning
• medical education
• undergraduate
• curriculum
• concept formation

Introduction

The concept of lifelong learning (LL) is a well-established pillar of professional medical practice and, consequently, medical training. Researchers in the field of medical education are often keen to justify their conclusions in its name and a cursory search for the terms lifelong learn* or life-long learn* across the journal databases will return thousands of entries. However, despite the ubiquity of the term, it is rare for any academic piece to present a working definition. This is not a new problem, nor is it exclusive to medical education. Contemporary discourses regarding the nature of LL and its ideological drivers have been manifold (Bagnall 2000) and have risked devaluing the concept to the point of redundancy (Field 2006).

In medical education, LL is often cited when examining learning theory, particularly self-directed learning theory (e.g. Greveson and Spencer 2005, Mazmanian and Feldman 2011) and self-regulated learning theory (e.g. Berkhout et al. 2018). It has been similarly linked to the concept of ‘generic skills’ as an objective of medical education (Murdoch‐Eaton and Whittle 2012), building on extensive previous academic dicourses which attempt to define the attributes required of graduates in the 21st century (e.g. Candy et al. 1994, Pitman and Broomhall 2009, Steur et al. 2012, Anderson and Normand 2017). In addition, a substantial proportion of the medical education literature sees LL linked to other overlapping concepts such as continuing medical education, continuing professional development, and recertification (e.g. Sehlbach et al. 2018).

Irrespective of conceptual confusion, LL is becoming an explicit outcome of medical training (General Medical Council 2018) and medical schools are, arguably, required to teach and assess knowledge, skills, and attitudes regarding LL to the same, clear, and objective standards as any other graduate outcome. A literature review carried out by the lead author (LA) revealed that despite a vast array of articles incorporating the term ‘lifelong learning’, very little investigates how LL is specifically being addressed in medical curricula and in what way it is being assessed. Notable exceptions are Ramamurthy et al. (2019) who quantitively measure students’ orientation to LL over the course of a medical curriculum and Brahmi (2007) who used qualitative data to examine graduating medical students’ conceptualisations of the subject. However, in both cases there is little exploration of how the medical curriculum contributed to these understandings and attitudes, which is a notable omission especially when one considers there is some evidence that capabilities for and attitudes to LL may actually deteriorate during training (Premkumar et al. 2013, 2018).

Arguably, the situation requires more attention because if becoming a ‘lifelong learner’ is an explicit outcome of medical undergraduate training then it should be clearer how competency is defined, taught, and assessed. As such, a study was devised by the LA as part of a master’s dissertation project at the University of Dundee School of Medicine (UoDSoM) to not only examine further students’ conceptualisations of and preparedness for LL at graduation but also, crucially, to begin to develop theory regarding how a medical undergraduate curriculum might influence this.

Methodology

Conceptual orientations

This exploratory study sought to authentically capture students’ conceptualisations of LL at graduation and to theorise causal links between these conceptualisations and the undergraduate curriculum. Recognising that the complexity of medical education often cannot be reduced to patterns of linear causation (Schuwirth and van de Vleuten 2019), the perspective of scientific realism was chosen. It offered a particular understanding of causation; that phenomena we can experience or observe are generated by events connected at a (usually) non-observable level (Greenhalgh et al. 2017a). At this deeper level exist mechanisms, ‘underlying entities, processes, or [social] structures which operate in particular contexts to generate outcomes of interest’ (Astbury and Leeuw, 2010). Realist inquiry, by identifying these context-mechanism-outcome (CMO) configurations seeks to develop theory about ‘what works for whom in what circumstances and in what respects, and how’ (Pawson and Tilley 2004, p. 2). Realism has been espoused as particularly suitable for studying how medical education interventions work (Wong et al. 2012) and, as such, it was chosen as an appropriate theoretical framework to support the aims of this study.

Setting

The UoDSoM MBChB degree is a five-year programme employing a spiral curriculum design (Harden and Stamper 1999) and utilising a variety of educational methods. The first three years are organised predominantly around body systems and principles of medical practice whereas clinical disciplines and preparation for foundation year practice underpin years four and five. Its approximately 1000 students are located mainly at Ninewells Hospital campus in Dundee – the setting for this study.

Study design

In realist research, interviews are used to develop theory (Greenhalgh et al. 2017b) as qualitative data are considered evidence of real phenomena (Maxwell 2012) and interpretations of qualitative stakeholder accounts can illuminate why a programme ‘works’ (Manzano 2016). For these reasons, semi-structured interviews were determined as the data gathering method. Semi-structured interviewing is familiar in qualitative studies, being particularly appropriate for investigating the meaning of phenomenon to participants and how this meaning has developed (Robson 2002, DiCicco-Bloom and Crabtree 2006, Starks and Brown Trinidad 2007).

Participant recruitment

All 150 final-year students were invited by email (initial invite plus one reminder) to participate, and an initial target of eight interviews was set in order to capture a range of variables in the study cohort, (age; gender; curriculum variations; and route of entry into medical school) and maintain a compromise with the practicalities of a master’s project. Ultimately six students (three males, three females) volunteered for the study. Their ages ranged from 23 to 31 years. Four had entered the programme as school-leavers, one as a post-graduate and one transferred in during year three from an international medical school. Four respondents had completed a one-year intercalated BMSc degree between years three and four. Upon discussion between the authors this was felt to be sufficient variation to proceed. The issue of achieving ‘saturation’ (the continuing collection of data until nothing new is generated (Green and Thorogood 2013)) was considered as it often guides decisions regarding sample size in qualitative research. However, it does not hold as much traction in realist research as, in this paradigm, any individual has the possibility of uncovering events and processes which can be explored in multiple ways to test theory (Greenhalgh et al. 2017b).

Ethical approval

Students were provided with written information regarding the nature and purpose of the research along with how their responses were to be utilised prior to consenting to proceed. Ethical approval of this study was granted by the UoDSoM Research Ethics Committee on 17^th of May 2019.

Data gathering

An interview guide (Supplementary Material 1) was created by drawing on the first stage (theory gleaning) of Manzano’s three-stage approach to realist interviews (Manzano 2016) in which respondents are expected to identify contextual circumstances that may have an impact on behaviour through general questioning about the programme. Each interview lasted approximately 30 minutes. As specific themes developed these were expanded upon as the interviews progressed. The LA conducted and audio recorded each interview which were subsequently transcribed to provide a data set for further analysis.

Data analysis

Data analysis, undertaken by the LA, was informed by Braun and Clarke’s (2006) six-phase process and, the realism aligned approach of Miles and Huberman (1994). These two conceptual positions were consolidated to provide a 5-stage framework for reflexive thematic analysis (Supplementary Material 2). This process was facilitated by the use of MAXQDA ™ software as follows:

Stage 1: summarising

Following transcription the audio files were summarised, beginning the analytical process. These summaries were framed around the concept of contact sheets (Miles and Huberman 1994, pp. 51–54) aligning initial ideas about the interviews with the research questions (see Supplementary Material 3).

Stage 2: generate initial codes

Interviews were then analysed in more detail employing a process of coding to bring units of meaning to the data and reduce its complexity (Gläser and Laudel 2013) and to facilitate a systematic approach (Pope et al. 2000). The coding decision-making was influenced heavily by Saldaña (2013). Firstly, ‘structural codes’ were employed to broadly relate the data to the research questions. Secondly, where the data suggested situations where resources provided by the programme triggered responses from students, ‘process codes’ were applied; using gerunds to indicate the possibility of causal mechanisms. ‘Versus coding’ was employed where phenomena were identified differently in different circumstances, indicating the influence of relevant contexts. Finally, ‘in vivo’ coding was used where the respondents’ use of language potentially illuminated their reasoning and meaning making. Simultaneous coding was utilised to allow codes to overlap and thus find commonalities between them and facilitate the later stages of analysis.

Stage 3: categorising

Coding was approached in an iterative manner. Through examination of each transcript the coding structure was refined and gradually organised into categories. During this process notes were written to keep account of coding decisions and developing theory, and either attached to the codes if relevant to the process of categorising and creating themes, or to the transcripts if the theorising had broader application to the data. This aligns with the concept of memoing (Glaser 1978; in Miles and Huberman 1994, p. 72).

Stage 4: generating themes

The use of simultaneous coding made it possible to visualise the overlap between codes and categories in the data. This, along with the collection of memos, became the starting point for the development of themes. Themes were developed through a process of theorisation which involved bringing together elements of the data, information gleaned from the literature review and prior scholarly knowledge.

Addressing reflexivity

On the matter of reflexivity, measures were taken to uncover implicit researcher bias, record and develop personal insights and evaluate the research process by opening it up to public scrutiny (Finlay and Gough 2008). To mitigate the risk of unconscious bias, a data gathering and analysis approach that was consistent with the philosophical paradigm was established in consultation with an experienced qualitative researcher, (second author), early in the process. The refinement of methods, translation of findings to themes and process of theorisation were all shared through further consultation, as well as through conference presentations and one-to-one discussions with other academic peers who had experience with realist methodologies.

Findings

Four themes emerged from the data analysis. Themes 1–3 relate predominantly to students’ understanding of the concept of LL and Theme 4 relates to their sense of preparedness for LL in professional practice.

In the pattern of data, themes relating to curriculum influences were interwoven diffusely with all other thematic elements. For efficiency of presentation and to maintain a sense of the narrative that emerged, data relating to such influences in this article are described as they relate to the other thematic headings.

Theme 1: characteristics of the learning process (understanding)

A core element of students’ understanding of LL was revealed in how they characterised the nature of learning. There were two main dimensions to this: continual learning, and the primacy of reflection.

Continual learning

Students conceptualised LL as a professional obligation to continually learn after graduation. This was closely linked to the perceived imperative to keep pace with the evolving requirements of one’s sphere of practice by furthering clinical knowledge:

Because when I think of lifelong learning, you know, medicine is a field where there is continuing development so you can never know everything … .That’s why I think of it as having to keep yourself up-to-date with ongoing developments and research as well as identifying any gaps and filling it in. (Interview 1)

Students related development of these understandings most strongly to their transition into the authentic clinical environment (ACE) during the clinical years of their programme. This transition appears to expose students to routine discourses and behaviours of practicing professionals, highlighting the cultural expectations of continual learning within the profession:

But it’s understanding why you need to be a lifelong learner … I think that comes in fourth and fifth year in the clinical environment more. You understand why it’s important, that you need to keep up to date … . (Interview 4)

The primacy of reflection

Students frequently associated the concept of reflection with how LL manifests in practice.

But it’s the act of stopping and thinking, reflecting on what you’ve done in the past that really helps the learning process in the future … . (Interview 2)

However, although reflection was well recognised as a fundamental aspect of professional practice, its ubiquity in professional discourses was seen to detract from its value, and moving past this was an important aspect of LL:

… people laugh about it like, oh you’ve got to reflect, like everyone kind of almost rolls their eyes at it … people see it as that sort of chore, and it’s not really … . (Interview 4)

The production of a comprehensive portfolio required for assessment was identified as the aspect of the curriculum most strongly associated with the reflective process and, consequently, the concept of LL:

I see [the portfolio] as a reflective journal of what I’ve done, what I’ve achieved, what I’ve not achieved, what I want to improve on. That’s the way it should be used. (Interview 6)

As with other aspects of learning relating to the concept of LL, the meaning and value of reflection is described as something that evolves predominantly in the latter years of the course as students move into the ACE:

… over the past six months or so it’s started to click with me about what [reflection] actually means, that it’s not just about kind of learning the course curriculum in order to pass the exam but actually it’s about something more important than that. (Interview 3)

Theme 2: lifelong learning bounded by the professional identity (understanding)

Within the data, aspects of learning were defined almost exclusively in reference to medical practice, to the extent that their concept of LL could be seen to have its own specific identity:

… medicine is quite different to many other courses … I think there’s a lot of different aspects which you have to balance and many different ways in which you have to develop yourself. (Interview 1)

There was a particularly close association between the concept of LL and career progression:

(Interviewer) So you’re framing the lifelong learning there in sort of getting to grips with the community of practice, is that right? Understanding rules and responsibilities? (Response) I think that’s a fair way of [describing] it … you’re seeing ahead and already kind of having an understanding of what your role is now and also what your role could be five years down the line. (Interview 3)

In addition, there was some suggestion that this special identity of LL was powerful enough to obscure the value of learning outside the boundaries of medical practice:

I’ve not really learned anything else to be honest … . I think it’s all been pretty much medicine driven. I don’t think there’s really been anything other than that that I’ve done that’s sort of improved my ability to learn. (Interview 5)

Some data suggested that this identity of LL begins to form early in the course, particularly in relation to summative assessment:

I remember approaching the third-year exam, and how I felt after. It was quite different from my peers. So, while most of them were saying, ‘ … ., that was too difficult and wasn’t fair’ and things, I was just thinking, ‘You know, well in the future when you become doctors, you can’t say that’ … that’s going to be medicine, you know. You’re going to see a patient that’s going to throw you off on the day. (Interview 2)

However, again, the ACE has notable influence:

I think everyone’s learning from [their] own mistakes and from what you see other colleagues doing. I suppose that I’ve been kind of learning from the FY1ʹs, the FY1ʹs have been learning from the registrars and registrars from consultants and they [are] constantly kind of trying to integrate what they see each other doing … . (Interview 3)

Theme 3: characteristics of the lifelong learner (understanding)

Respondents identified several personal characteristics required for successful LL. First was recognition of the need to take responsibility for one’s own learning and to develop necessary attributes to learn autonomously in clinical practice:

… learning is personal. It’s not always forced on you and especially, at post-graduate level, once you finish medical school, the decision, the onus is put on you … . (Interview 6)

Secondly was the requirement to maintain sufficient motivation for learning:

… definitely towards the end of your medical degree you really do grasp the concept that medicine is not a career that you get a degree and then that’s it … I think you’ve always got to have that personality trait to want to learn more as well. (Interview 4)

This was often seen as an inherent quality although influenced positively by the transition to the ACE:

So in some aspects it’s been there since I was a kid, throughout my entire … Starting from kindergarten and primary school, to where I am now. (Interview 2)

… being in the clinical environment and applying it, I definitely found this new passion for medicine and that made me, in my head, think right you are doing the right thing and that I now understand that it is quite hard work and you are going to have to keep learning and … have to want to sort of better yourself all the time. (Interview 4)

Finally, there were strong links made between having the capacity for critical thinking and conceptualisations of LL, often equating it with literature skills and research practice, particularly in the context of an intercalated BMSc:

… probably the best example of me improving my learning over the years would be my BMSc because that was completely different … there was more teaching about learning in my BMSc I would say. (Interview 5)

Theme 4: uncertainty (preparedness)

Students’ preparedness for LL manifested predominantly in their sense of understanding of the concept and the confidence with which it was described. Responses suggested that the students were confident in their capabilities upon graduation and trusted that the medical curriculum had prepared them sufficiently:

Dundee and the MBChB programme has done everything right and everything it can do to prepare me for what comes ahead and it’s down to me about whether I utilise these [LL] skills … . (Interview 3)

However, despite this, there appeared to be an undercurrent of uncertainty across the respondents, with direct evidence that conceptions of LL had been left to hidden elements of the curriculum.

I can’t really define my skillset for lifelong learning I have to tell you. (Interview 2)

I don’t think I’ve ever really thought about [LL] before and I don’t think anybody really talks about it and I think it’s just something that everyone kind of does without meaning to do it. I think it probably would be good if somebody sort of fed it into the curriculum. (Interview 5)

Although separated out for the purposes of presentation, the themes derived from the data analysis were deeply inter-related in the narratives of the individual respondents.

Having established the themes, the final stage of analysis is to discuss and draw conclusions. These will be considered in the following sections.

Discussion

Given that the main aim of this study is to begin to develop theory regarding how students’ conceptualisations of LL form during medical training, it is important to reinterrogate the literature to identify any relatable established theory or other academic discourses which support any conclusions made. This section summarises that reinterrogation as a brief narrative, drawing in the themes from the findings.

The requirement to ‘keep up’ in medical practice is well recognised, whether it be simply to maintain efficient working knowledge (Laine and Weinberg, 1999) or more broadly be able to ‘cope’ with the demands of contemporary medical practice (Teunissen and Dornan, 2008). Students’ responses reflected this and align with broader discourses regarding the need for graduates to manage rapidly increasing bodies of knowledge in the face of rapid and pervasive societal change (Candy et al. 1994; Knapper and Cropley, 2000). They are also consistent with the small amount of prior literature examining medical student definitions of LL on graduation (Brahmi 2007).

Assumption of personal responsibility for learning was a key element of students’ understanding of LL and this is inherent in learning theories where learner autonomy is considered significant, such as self-directed learning (Brockett and Hiemstra, 1991; Candy, 1991) and self-regulated learning (Zimmerman, 1989). The capacity for critical reflection is considered a major factor underpinning this autonomy; a mechanism for transformation of the individual, making sense of experience, and facilitating change (Boud, Keogh and Walker, 1985; Mezirow, 1985; Kolb, 2014). Although not articulated specifically in this way by respondents, the data makes plain that they also identified reflection as a key element of their conceptualisation of LL and, in terms of curriculum interventions, was strongly linked by students to the concept of the educational portfolio.

Research and the capacity to engage critically with medical literature were also identified as a key aspect of LL. Information literacy skills and a ‘critical spirit’ have been espoused as key components of LL (Candy et al. 1994). These attributes are considered part of a set that underpins graduate effectiveness and adaptability and is reflected in contemporary discourses surrounding LL (Murdoch‐Eaton and Whittle 2012).

Throughout the data, students’ transition to the ACE appears to have the most significant influence on their conceptualisations of LL. It seemingly engenders their perspective that LL is, to a large extent, learning how to participate. Learning as participation is not only a recognised concept in itself (Sfard, 1998) but the foundation of learning theories such as situated learning (Lave and Wenger, 1991) and the concept of communities of practice (COPs) (Wenger-Trayner and Wenger-Trayner, 2015). It can be seen, perhaps, how the influence of a COP may shape conceptualisations of learning. The primacy of reflection is a good example here, being a well-established tenet of professional medical practice which the respondents strongly associated with LL. There is also a suggestion from the respondents that learning to participate is motivating, with motivation being identified by association as a key aspect of LL. This correlates with self-determination theory (Ryan and Deci, 2000), which proposes that motivation is strengthened most by activities that facilitate a sense of autonomy, competence and relatedness, and has been espoused as an important contributor to the development of LL skills (ten Cate, Kusurkar and Williams, 2011; Schumacher, Englander and Carraccio, 2013)

Given then the impact of the ACE on students’ sense of understanding of and preparedness for LL it is perhaps unsurprising that there was some sense of restriction; that the identity of LL was tied to and bounded by the norms of the medical COP. Having conceptions arise in this way and, as the data suggests, in the absence of formal teaching on the topic, one can argue that it is predominantly a product of the hidden curriculum rather than an explicit outcome of the teaching programme.

Limitations

This study is limited by being situated at a single institution and drawing on a small number of responses. It is possible the respondents held an atypical enthusiasm for the subject matter and there may also be an element of social desirability bias in their responses. The study suggests a disproportionate influence of the later years of medical training. It is possible, however, that the influence of earlier elements of the curriculum have been overshadowed either by the motivational potency of being allowed to participate within the ACE or, perhaps, have simply faded over time.

Conclusions: the conception of a theory

The culmination of this study is to proffer a provisional theory, structured around a configuration of contexts, mechanisms, and outcomes, describing how a medical undergraduate curriculum influences students’ capacity for LL (Figure 1).

Figure 1. Proposed ‘CMO’ configuration regarding lifelong learning in undergraduate medical training. Adapted from Bartlett, M., Basten, R., & McKinley, R. K. (2017). Green shoots of recovery: A realist evaluation of a team to support change in general practice. BMJ Open, 7(2).

This theory proposes that a medical undergraduate curriculum, sitting within a medical COP, influences students’ understanding of LL predominantly through access to the ACE, the use of educational portfolios and access to academic research programmes. These resources, unfettered by structured or formalised teaching regarding the concept of LL, expose students to prevailing discourses and attitudes regarding LL which reflect professional cultural norms. This enables students to relate the concept of learning to projections of their future roles and potential career paths and facilitates a greater sense of relatedness with the COP.

As well as increasing a sense of relatedness, these resources also provide opportunities for greater autonomy in learning and a greater sense of responsibility, which are powerful motivators for learning. Recognising this, motivation to learn and the responsibility to learn becomes part of students’ conceptualisations of LL alongside having the capacity for critical thinking and recognising the key role of reflection. This conceptual framework for LL is identified almost exclusively by its relationship to medical practice and, as students participate further in the medical COP, this identity is reinforced. Ultimately, as this identity develops within a student and aligns itself with professional norms, a sense of preparedness for LL in practice manifests.

Strengths and future research

This study is thought to be the first to attempt to propose theory regarding how students’ conceptualisations of LL are formed during medical undergraduate training. Given that the demonstration of LL skills has become a required outcome of contemporary medical degree programmes, conceptual clarity is, arguably, essential, as is the need to understand the relative contributions of specific curricular elements to students’ attainment of these outcomes.

The study is situated within a complex programme influenced by many contextual factors, and, in the spirit of realist enquiry, this provisional theory is provided to generate discussion and as a platform for further research. Future studies might examine to what extent the apparent outcomes of the programme suggested by this study are the intended outcomes and whether students’ understanding of LL are truly consistent with those of the professional milieu they are about to enter. Interrogating the assumptions made by faculty regarding these issues would perhaps be a valuable next step. This research also raises the question as to whether the concept of LL is discipline specific. Conducting similar studies in different vocational training programmes may help answer this and may also begin to offer a degree of generalisability to theory about how lifelong learners develop and how higher education institutions can best provide support.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/25783858.2022.2133624

Additional information

Notes on contributors

James C. D McMillan

James McMillan is a sessional general practitioner in the Tayside region and a senior clinical teacher in the School of Medicine at the University of Dundee.

Linda Jones

Linda Jones has a background in social work and is currently a senior lecturer in the Centre for Medical Education at the University of Dundee.