How can trainee health professionals learn from the ‘messy reality of actual clinical practice’? Wendy Lowe reviews a new book exploring what learning is, or should be, in medical education.
Moments of Rupture combines a deft portrayal of three of my favourite subjects: medical education, narrative and learning. With surgical precision, Moments of Rupture is a meticulous anatomical dissection of what it means to learn and how we do it. The distinctive title refers to how clinical events (disturbances or punctures) can function to rupture standard healthcare practices; the book explores the value of understanding our affective responses to these events, in order to learn from them. The skill of the book lies in the clarity with which difficult philosophical terms are weaved into a biomedical context. The integration of these difficult concepts into an accessible, pragmatic book for surgeons and other healthcare professionals is an enormous achievement. The book is just the right size to be manageable and does not overwhelm the reader with difficult terminology: if you are looking for an introductory text on the sociology of learning as it applies to healthcare, then this book is for you. This book will also be useful if you are a healthcare professional embarking on a higher degree in education and require some of the concepts to be explained in a practical way.
The first part of the book introduces theory and terminology through a discussion of experiences of learning during clinical practice. Chapter One introduces the struggles of learning within a clinical situation, where the gap between theory and practice is unpacked via a discussion of what happens in the space in between the two. ‘Ruptures’ are disturbances occurring in the messy reality of actual clinical practice; they provide moments in which practice can come into clearer focus, if we have the tools and are willing to pause and use them. These disturbances can also require practitioners to ‘become undone’ ‘when forced to challenge the established knowledge and practices in an attempt to grasp the potential of the unknown’ (p. 10). Moments of Rupture introduces the idea of the ‘encounter’ with the potential for the speechlessness of experience: “I am slowed down and suspended in a dimension that precedes consciousness, where cognitive processes are yet to emerge and organise the experience through language, logic and reflection” (p.11). These arresting moments, where the focus is on sounds, smells, images, are so-called ‘local flows of experience’, which are distinguished from the work of memorising and reproducing routines. Mahendran’s voice comes through clearly; it is a pleasure to hear its no-nonsense exploration of alternative theories of knowing and doing that are based on awareness of affective dynamics in the clinic. This presence of the author’s voice helps to reduce the formality and complexity of an academic text about learning.
Chapter Three explores the Pedagogy of Encounter in more detail – that is, the moment when you fall off the cliff of established learning, guidelines and policy. The chapter explores what happens when the subject or learner crosses the invisible border between the routine and the unexpected. Then, in Chapters Four and Five, Moments of Rupture explores the tension between professional bodies’ guidelines for practice and caring versus the actions that may be enabled by uncertain, unfamiliar events. This is a difficult section in that the clinician reader feels compelled to choose between the two, when perhaps what is needed is an exploration of the relationship between simple, reductionist, explicit guidelines and the complexity of unknown situations. Perhaps the former may be looked upon as the scaffolding for a basic ethics of care and the latter as a more nuanced analytic procedure for inspirational care. Indeed, it has been suggested that during moments of extreme pressure and uncertainty it is the medical techniques themselves that have allowed clinicians to continue on, rather than becoming overwhelmed by circumstances. Drawing on Kohlberg’s notions of different types of morality, there could be a place for different types of learning for people at different stages within their learning journey, as well as a place for an understanding of the relationship between the different philosophical and ethical perspectives.
Chapter Six tackles a really challenging issue: the difference between education and training. Moments of Rupture explores the liberal arts versus techno-rationalist debate about curriculum development that has dogged the (medical) educational field for decades. That is, the chapter looks at the differences between education (in a broad, humanities sense) and training (in a narrow technical sense) in intent, outcome and meaning. The book explores the relationship between two conceptualisations of training: reductionism, which is based on the assumption that learning can be controlled and defined in advance, and emergentism, which is based on the assumption that learning emerges in the moment as a result of experience. For example, the book considers the difference between individual learning (competency-based training) and communities of practice (where the emphasis is on relationships and social learning); it also reflects on the disconnect between learning objectives and the question of what constitutes a good teacher and good teaching. These are all current issues in the medical education literature, yet there has been little concrete exploration of the implications of complexity and uncertainty in the clinic for healthcare practice, nor of the affective dimension of learning and training. With the current state of the NHS and health inequalities, it seems as if Moments of Rupture is a book for the times, as it enables the articulation of lived experience alongside the instrumental curriculum of medicine.
Overall, this is a carefully written, accessible introduction to teaching and learning which takes us into new territory, treading unfamiliar conceptual ground for medical education. The book offers educators new tools, enabling them to move beyond rhetoric and take footsteps across the so-often treacherous theory-practice gap. Moments of Rupture is elegant and forthright: two much-needed qualities in medical education and in medicine generally. One can imagine, with this book in their compendium, that the clinical teacher and clinician will be more confident about what to do, and how, during these moments of disruption and emergence of the unknown. Moments of Rupture opens a three way conversation between traditional apprenticeship learning, competency-based instrumental learning, and the issue of what to do when you don’t know what to do. In a way, a gauntlet has been thrown down to medical educators: Moments of Rupture provides integration and progress within this field. In the author’s words: “[d]eveloping and promoting such strategies within medical education is to configure learning in clinical environments as an adventure, where the outcome is uncertain and the modes of becoming unknown yet soon to be” (p.55).
Moments of Rupture: The importance of affect in medical education and surgical training by Arundathi O. Mahendran was published in 2020 by Routledge.
Wendy Lowe is a Senior Lecturer in Medical Sociology and Medical Education and Module Lead for the Human Science Public Health module in Years 2 and 3 of the MBBS and GEP at Barts and The London School of Medicine and Dentistry. Her PhD explored how health professionals are educated.