Learning support for the consultation: informationsupport and decision support should be placed in aneducational framework

Paul Robinson,1 Ian Purves1 & Rob Wilson2

Background Advances in information technology mean

that it is now possible to provide contextually relevant,

evidence-based information during the course of the

consultation. As a consequence, the practitioner has to

consider the new information (from the computer) in

the situation of the present consultation and in the light

of his or her own experience. This task has to be carried

out in a short time, in the presence of the patient.

Method Drawing on experience of the development of

one decision support system, this paper places that task

for the practitioner in an educational framework. We

begin by reviewing theories of professional experience

and knowledge and go on to look at schema theory and

the role of cognitive dissonance and reflection in

learning.

Conclusion This paper considers the provision of real

time decision support in the light of learning and the

experienced practitioner. We conclude that framing the

implementation of decision support in this way pro-

vides useful insights. The key process is learning by the

practitioner, in the course of the consultation. This

process should be supported by decision support and

information support software. There are implications

here for the design of such software, and also for the

way in which practitioners are trained to use it.

Keywords education, medical, continuing ⁄ *methods;

physicians, family ⁄ *education; decision making; profes-

sional practice ⁄ *standards; *learning; Great Britain.

Medical Education 2003;37:429–433

Introduction

Primary care in the UK is mostly computerised (in 2000

99% of GPs used computers for repeat prescribing and

85% used them, at least partially, for making medical

records)1 and has provided a setting for the development

of computerised decision support systems. It is now

possible to provide contextually relevant, evidence-based

information during the course of the consultation. As a

consequence, the practitioner has to consider the new

information (from the computer) in the situation of the

present consultation and in the light of his or her own

experience. This task has to be performed in a short time,

in the presence of the patient. The key process is learning

on the part of the practitioner, in the course of the

consultation. This paper reviews theories of experience,

knowledge and learning. It goes on to consider how

learning by the practitioner, during the course of the

consultation, might be supported.

In their review, Delaney et al.2 describe the potential

for computerised decision support to deliver improved

quality, but conclude that this potential has not been

realised. Although we would debate Delaney et al.’s

view, especially in the context of PRODIGY,3 we believe

there is great potential for computerised decision

support. The systems so far developed fail to meet the

needs of the practitioner and the patient in the primary

care consultation: a �sophisticated understanding of the

process of the consultation is required�.2 We have in the

past described such a process for the consultation4 and

believe firmly that the �system� is much wider than the

computer, its software and its knowledge bases: it

involves both the clinician and the community in which

he or she lives. In this paper, we suggest that what is

needed is not decision support, nor information sup-

port, but learning support.

The ideas that are developed in this paper arose from

an iterative development of the PRODIGY project and

from research into the use of knowledge during the GP

1Sowerby Centre for Health Informatics, University of Newcastle, UK2University of Newcastle Business School ⁄Centre for Software

Reliability ⁄Centre for Urban and Regional Development, University

of Newcastle, UK

Correspondence: Dr P J Robinson, Wayside, Pickering Road East,

Snainton, Scarborough YO13 9AF, UK. Tel: 00 44 191 243 6000;

Fax: 00 44 191 243 6101; E-mail: p.j.robinson@ncl.ac.uk

Learning support

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:429–433 429

consultation.3,5 The aims of the first two phases of the

PRODIGY system were to deliver prescribing therapy and

condition management advice (�clinical recommenda-

tions�) to the general practice clinician at the point of

care, in this case the consulting room. The general

practitioner (GP) utilising the system during Phase 1

was presented with therapy options usually consisting

of three drug preparations, but for some conditions the

option of a patient information leaflet was also available

as an alternative. Extensive evaluation, using a pre-post

intervention trial model, was carried out.6 This inclu-

ded focus groups, video-recorded consultations, user

questionnaires and computer generated interaction log

files of usage. This led to both improvements (including

the insertion of �scenarios�) and greater understanding

of the participating GPs’ use (and non-use) of the

system, leading to a Phase 2 trial system and thus

completing one iterative development cycle. The same

model was then used to evaluate the Phase 2 system

before culminating in a nationally available version

(Release 1). PRODIGY is a mixed cognitive and rule-

based system, which is founded on guidelines that

advise on therapeutic actions such as prescriptions,

advice leaflets, referral and investigation.

The research into knowledge use during the consul-

tation5 found, in nearly all consultations studied,

instances of cognitive dissonance between action that

the GP knew to be recommended by published work

and action that was based on his or her own experience.

Practitioners nearly always chose to follow the latter.

The difference between guideline recommendations

and what the practitioner in fact decides to do is

analogous to the research–practice gap.7 We work

from the premise that, in order to make good use of

on-line decision support, the practitioner has to learn

in two areas: how to incorporate into the consultation

information derived from the computer, and how to

adapt clinical practice to the guideline recommenda-

tions.

The GP’s experience

Even the newly appointed GP Principal has consider-

able experience of and expertise in medicine, consulting

with patients and working in primary care. The

development of expertise in medical practitioners and

the role of experience in learning have been well

described.8–10 Qualitative analysis of knowledge use

by GPs during the consultation5 shows that, during a

consultation, the GP’s conceptualisations interact with

and integrate knowledge derived from four different

sources: the literature, colleagues, the patient and his or

her family, and the doctor’s own memory and experi-

ence (see Fig. 1). These sources (excluding colleagues)

correspond to Popper’s World 3, World 1 and World 2,

respectively.11 That is, the written record and the

literature are objective structures produced by people;

the symptoms and signs of patients are, for the GP,

material things; and memory and experience comprise

the subjective world of the mind.

Although this model is cognitively derived, it is

consistent with social learning theory.12 Learning is

situated within the consultation, and the participants in

the consultation constitute a community of practice.13

Communities of practice are forums in which joint

participation leads to shared understanding and defini-

tions of meaning. The doctor is also a member of other

communities of practice, namely the participants in

other consultations, the primary care team and the

medical profession.

Key learning points

Dissonance is a prerequisite to learning.

Dissonance is emotional and frightens people off.

This provokes a need to help GPs develop schema

to cope with dissonance.

Learning is situated in the consultation.

Learning support needs:

• to tell a story (intuitive) based at population

level and adapted to the individual patient (if it can

be);

• to support just-in-time learning, and

• to induce post-decision dissonance and support

constructive learning (i.e. through action support;

reflection support after consultation).

Figure 1 The GP’s experience; literature refers to the written

medical record as well as to papers and textbooks.

Learning support for the consultation • P Robinson et al.430

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:429–433

The implication of Fig. 1 is that the GP’s current

experience should be informed by all four sources.

Unless written material or colleagues’ advice or infor-

mation about the patient is directly sought during the

consultation, it is represented in the consultation via

the GP’s memory. The literature is considered part of

the GP’s experience, rather than separate and different

from it. Alternatively, it is possible for the GP to relate

only to his or her own memory and the patient. This is a

mechanism by which rigid habits can develop, to the

exclusion of research or audit findings. The social

context of the GP consultation may encourage this.14

Experience and expertise constitute a conundrum. On

the one hand, they are a practitioner’s greatest assets;

indeed, in Kant’s view experience is all that any individ-

ual can have. On the other hand, �experience� may be

synonymous with resistance to change.15 Straddling this

divide is the view that teaching is most effective when the

learner’s previous experience is taken into account.16

As Dowie7 describes, research-derived knowledge is

fundamentally different in character from practitioner-

based knowledge. The experienced practitioner has a

knowledge structure that is based on illness scripts or

case memories.8 These are remembered and related as

stories, and there is a new appreciation of the import-

ance of narrative to medical practitioners.17 Stories are

built up from schemata, which we describe below.

Schema theory

Any perception of the world is interpreted through a

person’s schemata, or organised knowledge of the

world. These schemata are the basis of comprehension,

learning and remembering. Ideas sit in the �stories� in

which the human mind embeds its sensory percep-

tions.18 They can be viewed as structured expectations

about people, situations and events.

There are differing types of schema:

1 Person schema, in which we hold our perception of the

characteristics (skills, competencies and values) of an

individual. �Self � is a specialised person schemata.

2 Event schemata, or cognitive scripts, that tell us how

to behave in differing situations.

3 Role schemata, which are third-person event sche-

mata or models that we can use to predict how others

might behave in certain situations. We can apply

these to simulate �event schemata� and this can be a

route to the development of personal event schemata.

These schemata are developed either directly from

personally refined (act–observe–review) events or indi-

rectly through others’ stories. Stories are built around

actions taken by �actors� and ⁄or �things� within an event.

Stories also have plots which link events backwards in

time and �predict� potential future events. Of course,

stories can be narrated using many differing forms of

discourse, whether it be thought, spoken, written or

acted using a variety of media.19 Initially, schemata are

simple but they become more complex, interwoven and

�specialised� over time. Schemata are in effect narratives

with the discourse as the distributed representation in

the brain.20,21

Everything we perceive is pattern-mapped into our

many schemata and, as we become more experienced,

we develop highly specific schemata that enable inter-

pretation – when we are less experienced we use less

refined schemata.8 This human mechanism is highly

effective and, despite our amazing developments in the

computing field, is not reproducible, on a usable scale,

even at an embryonic level.22 However, the �human

mechanism� does have drawbacks as everything we

perceive is filtered by our schemata to the extent that, if

we have well-refined and heavily weighted schemata

that are relevant, we can �throw away� perceptions that

do not �fit� our experience.

Of course this implies that schemata can be fairly

rigid: nothing is further from the truth – they are

dynamic. There is a spectrum between no experience

(i.e. no relevant schema) and expert (i.e. highly

specialised schema). If we have no schema we develop

new ones, we find a schema that partly matches, and we

adapt it and create a further specialisation. Problems

occur if we have inappropriate rigid attitudes (self

schema), or perceptions or advice that conflict with

highly specialised schemata. In this situation there is an

emotional discomforting response of cognitive disson-

ance. How we deal with this dissonance determines

whether we learn.

Cognitive dissonance

Cognitive dissonance is the perception by a subject of a

difference, of variable intensity, between what has been

previously perceived and learned (i.e. schemata) and

new information. Cognitive dissonance theory tells us

that we try to reduce or avoid the discomfort.23 Clearly,

dissonance is a common occurrence as we interact

with our environment, especially with our peer group,

and the intensity of the dissonance depends on

how we perceive the competence of the person or

group expressing the contradictory opinion and our

emotional relationship with the person or group. It is

fundamentally the result of a reflective process, which

may involve either reflection in action24 or delayed

reflection. How we react when we face dissonance falls

into the following responses:

Learning support for the consultation • P Robinson et al. 431

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:429–433

1 we dismiss the message (story) as being unimportant

or wrong;

2 we dismiss the messenger (narrator) as unimportant;

3 we seek corroboration in the environment in support

of the new information and incorporate it into the

personal schema, or

4 we attempt to reduce the dissonance by negotiating

with the messenger, or, if this is not possible, we

accept the message and change the personal schema.

The easiest responses are types 1 and 2, especially if

we have developed schemata to support these behav-

iours. However, we learn nothing with such rigid

responses and can only learn with responses 3 and 4.

Cognitive dissonance is at the root of all learning and

strategies to induce dissonance, or �learning-by-disturb-

ing�25 are important. Practical support is needed to

optimise responses 3 and 4.

Reflection

Activity and reflection are two integral parts of the

learning process.10 In our context, �activity� is the

awareness of experience. Reflection may occur at

different times in relation to the activity. Schon24

describes how expert practitioners are able to reflect in

action. This process is often subliminal: it works on

automatic pilot. At higher levels of challenge the

practitioner may need to stop and think, perhaps

deferring a decision until this has been accomplished.

Schon also relates how an intuition that �something

does not fit� may not interrupt the practitioner’s flow,

but may be resolved on later reflection. Eraut26

describes in teachers the ability to store �film clips� of

classroom episodes. These may be replayed weeks or

months later and provide material for reflection.

We have considered how cognitive dissonance arises

when schemata pertaining to the same event conflict

with each other. Reflection (�the reconstruction of

experience�)9 is the process by which schemata are

compared, and so may come into conflict. This

reflection, and therefore dissonance, may arise in

action, during a pause in the action, shortly afterwards

or a long time later.

Implications for learning

We have described ways in which the GP’s experience

is socially determined and represented in cognitive

constructs (schemata), which contain narrative and are

expressed in narrative. If research-based knowledge is

to be used by a practitioner, it must become part of his

or her experience. The challenge of getting research

findings into practice becomes the task of incorporating

new information into the practitioner’s existing sche-

mata, and developing schemata to utilise learning

support appropriately. In other words the task is to

help the practitioner to learn. Further, the learning

required is situated in the consultation. How is this

learning to be supported?

Part of the solution is to provide information at the

point of care.27 If this information is in conflict with the

practitioner’s experience, it will lead to dissonance.

Cognitive dissonance is a necessary precursor of learn-

ing, but it can also lead to emotional tension and

avoidance of learning. In the nature of reflection, the

dissonance that occurs may be appreciated at the time

or later, during the consultation or after it. Learning

can take place outside a consultation, within a com-

munity of practice, as long as the story is simulated and

related to the consultation. In this situation the patient

is represented by an instance (case memory), and the

evidence by an illness story. The learning consists of

bringing the two stories together.

Gaining expertise implies the development of spe-

cialised schemata that frame perception and tend to

discard new information that does not match experi-

ence. In an unchanging world that had itself become

highly specialised, this would not be problematic.

However, in a complex, generalised environment where

the domain knowledge changes rapidly, there are issues

of updating schemata. Of course the brain is itself a

complex system and highly adaptive – what is required

are schemata that prepare us to constantly challenge

personal experience. These schemata need to be part of

professional culture, and developed in the community

of practice. They should also be general purpose

schemata that the individual can adapt to their own

circumstances. This type of schema is often best

communicated by metaphor. For example, the meta-

phor of education as a journey is a general purpose

schema that explains and supports personal change.

Conclusion

This paper is written from the point of view of Primary

Care in the UK. The issues discussed apply to the use

of on-line decision support in any medical context.

In the information age, what identifies the professional

is not information, as this is ubiquitous, but experience.

Traditionally, the doctor has been seen, or has aspired to

be seen, as a scientist who uses logical analysis and

hypothetico-deductive reasoning to solve clinical prob-

lems. In fact, hypothetico-deductive reasoning is not a

cognitive process but a schema, and we have tried to

move forward by replacing this view with a model of

Learning support for the consultation • P Robinson et al.432

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:429–433

experience that takes account of cognitive, social and

affective factors, and that identifies the learning methods

that enable evidence to get into practice. To make the

best use of what computerised decision support has to

offer, the individual practitioner is required to make use

of a variety of schemas, of which hypothetico-deductive

reasoning is only one. The link between these factors lies

in narrative, and we believe that learning support in the

consultation should reflect this.

As well as providing information at the point of care,

effective learning support depends on the practitioner

having schemata that help him or her to make positive

use of cognitive dissonance. Learning support needs to

provide practitioners with these schemata. It needs to

present new information in a way that takes account of

the practitioner’s experience and narrative structures. It

also needs to support learning at different stages in the

consultation and its aftermath.

Contributors

The ideas for this paper were developed by IP and PR.

RW provided details of the PRODIGY evaluation. All

three authors were involved in preparing the text.

Acknowledgements

We thank Nick Booth, Alison Evans and Phillip

Heywood, who all provided thoughtful feedback on

early drafts of this paper. We are also in debt to those

colleagues with whom we have exchanged ideas about

education and decision support.

Funding

None.

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Received 13 October 2000; editorial comments to authors 22 February

2001, 6 October 2002; accepted for publication 20 November 2002

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