An education in (social) practice

Author: Nikki Abela / Codes: CC8 / Published: 20/03/2017


The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

The thing I hate most about medicine is that dreaded feeling, when you are walking the dark hospital corridors at night, on your own, and the bleep goes off again.


Oh yes, you know the call from that ward again (the one you just left) because the patients cannula fell out.. again (the one you just put in, 3 times in the last hour).

What was that again? Oh yes, a bad dream. Because I no longer do on calls, on my own, slave to bleep because now I am part of the ED the best team in the world.

The lonely days are over. We may be busy, we may be overworked, but at least we are in it together.



The truth is that you are never alone in an ED (unless you work in the middle of nowhere, perhaps) and are constantly surrounded by peers, seniors, juniors, nurses, sisters, different specialties and of course, patients (lots of them).

This social context is central to learning from an EM perspective, and how trainees feel in that community is a vital part of their education.

This theory of Socio-Constructivism dictates that individuals first learn through social interaction and later by internal construction and this is where the ED excels: it gives us the opportunity to test what we know and measure it up against others knowledge of our truth. For example, think about how when you refer patients, the specialist will challenge your ideas, or when a junior shops around for advice, they are essentially trying to measure up what they know about a certain condition and align it with what more experienced physicians practise.

This social discussion allows individuals to build on their foundation knowledge and measure these ideas up against those of others in the group, enabling a deeper understanding of what they know. Another place where this happens is on social media, where people engage with a certain tweet and deconstruct its message, learning socially, before constructing knowledge internally.

Think about what you know about cardiac chest pain. You may have seen a patient with what you think is possibly ischaemic sounding pain, but it doesnt quite fit, he says it is indigestion and his ECG is normal but he looks awfully sweaty and is vomiting, so you decide to ask an experienced colleague what they think. She tells you the patient looks like he is having an MI (you may have never knowingly seen a patient actively having an MI, so you add this image to your brain encyclopaedia), and the fact that he looks sweaty and vomited are two strong features, so you take her advice and refer the patient to you the medics. Low and behold your gut feeling was right and his troponin comes back high and coronary angio shows an occlusion.

This dialogue has augmented your knowledge on cardiac chest pain you saw the patient and thought, I think this guy is having an MI, but you werent sure why. Your colleague tells you that those two associated symptoms are strongly related to cardiac pain and she also points out that the description of the pain is a weak factor. You later stumble upon one of Rick Bodys awesome posts (it was posted on your friends twitter) and you read that if the patient vomited with their pain, theres a 41% chance that theyre having an acute MI and the patient looks sweaty, theres a 59% chance that its an acute MI. Moreover, the character of a patients chest pain really doesnt change the probability of an acute MI as if the pain is heavy or crushing in nature, the probability of an acute MI shifts only from 19% to 22%. You internalise these ideas for future reference.

This is socio-constructivism where these platforms for learning, both in the ED and online, make our society a powerful educational tool. In the 1990s Lave and Wenger coined the term Communities of Practise to describe how a group of people who come together to share what they know. These communities are different from formalised learning or professional groups as they typically form spontaneously through social interactions. The FOAMed community, you could argue, is typically like this.

Even more so in the ED, where mutual engagement, joint enterprise and shared repertoire is an excellent community of practice for physicians and allied health professionals to flourish.

Building on the theories of socio-constructivism and communities of practise, adult learners therefore will not be taught something new, but rather build their own new knowledge for themselves on their preconceptions through social interaction in the communities they form.

Take thoracotomies as an example. This sexy topic has received much social discussion online, and as a result, more of us have taken the time the learn the theory behind it. Our very own Simon Laing confessed in an RCEM conference some years back that the very first time he performed one, he did it after hearing a podcast which was posted on twitter. Listening to this podcast, along with watching YouTube videos and mental simulation made the procedure possible to complete with relatively much less stress.

Moving on from the theories of communities of practise and socio-constructivism, is a meta-theory by Illeris which hypothesises that through these systems it is not only the individual which learns, but also the groups and organisations as a whole.

Building on this then, having a culture which harnesses learning will not only enhance the ability of the learner, but also of the department, and that of the medical sphere they practice in.

Taking FOAMed as an example, it is thought that through this socialized learning, both the individuals practicing it, and the FOAMed community have advanced in their medical practice collectively. An example of this is that of the SGEM whose goal is to cut the knowledge translation window of evidence on publication from over 10 years down to less than 1 year.

Therefore if this meta-theory is correct, how much more important is it, now that we may deduce that collective learning has a knock-on effect on its medical organization, that we, as medics, cultivate a society open to enhanced learning.


Much of this blog has been inspired by the EM Zen section in St.Emlyns blog. If you want to learn more, definitely visit this site.

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