The Academic Life in Emergency Faculty Development people are back! If you loved the first edition of Education Theory Made practical, you are going to be really happy. Staring this month, the ICE blog is going to serialize 10 chapters of Volume 2 of this series. Every Tuesday (with a couple of interruptions for our regular broadcast) there will be a new chapter released.
But, there’s a catch. We need you to help with open peer review. Before the book goes to publication, we want the #meded community to review the chapters and provide comments (at the bottom of the ICE post). These comments will ensure the quality of the final version of the book.
Also… it’s free. The ALiEM Facubator will be distributing the ebook free to the entire health professions community. This seems like a pretty good exchange.
Don’t be intimidated by the review process. You don’t have to be a content expert on education theory. You don’t have to go through each chapter line-by-line. However, as a ICE blog subscriber, you are the target audience for this book. Your opinion really matters. What part of a chapter is confusing? What favourite resource is missing? What application didn’t make it to the final cut that you want included? Your comments are key to this process.
Let’s get started.
Zone of Proximal Development
Authors: Lee Eisner, Dina Wallin, Andrew Vincent
Editor: Daniel W. Robinson, MD
Main Authors or Originators:
Lev Vygotsky was a Russian psychologist and social cognitive theorist who died young in 1934 before fully developing his work on ZPD.1 He was both influenced by and confined by the pervasiveness of Marxist doctrine in intellectual and political circles at that time. Later in the 20th century in the West, his work was dissected, edited, expanded, possibly altered, and published posthumously in the West in multiple publications. His theories are considered to have influenced the development of social constructivism.
Part 1: The Hook
You are the director of your medical school’s Critical Care Pathway (CCP), a year-long longitudinal course catering to students applying in Emergency Medicine, Anesthesiology, and other specialties managing acutely ill and injured patients. You have a total of 30 students in the CCP; Anna and Nic are two of your fourth-year students one month away from graduating medical school and starting residency.
Anna is going into Emergency Medicine. She’s received outstanding evaluations on all of her clinical rotations, especially her Emergency Medicine sub-internships, with multiple supervisors commenting on her exceptional fund of knowledge. She’s very excited to finally be a “real” doctor but is worried that she’s never managed a sick patient without constant direct supervision. Her first rotation of residency will be in the medical intensive care unit (ICU), and she’s overwhelmed by the fact that she will be immediately responsible for multiple critically ill patients, some of whom will go into cardiac arrest during their stay in the ICU. She has read the chapters in her textbooks concerning the cardiac arrest and is capable of reciting a long differential diagnosis for the acutely decompensating patient, but has no idea how actually to manage these patients and “run the code.”
Nic is going into Anesthesiology. He completed multiple away rotations at prestigious programs and received numerous evaluations describing his outstanding bedside manner and communication skills. He is extremely well-liked among his peers and seems to be a natural team leader. Because he’s already completed several Anesthesiology clerkships, he feels confident in his procedural skills, especially with intubation and obtaining vascular access. However, he’s had some difficulty explaining core pathophysiology when asked questions by his supervisors, and required remediation after failing his Internal Medicine shelf exam as a third-year student. He will also start residency in the ICU, and is terrified of the complexity of these patients, recognizing his relatively weak grasp of physiology.
Anna and Nic are not alone among your thirty CCP students in their fears about starting residency, through each student bring a unique combination of prior experiences, strengths, and weaknesses. How can you make the last month of medical school worthwhile for such a diverse group of learners?
Part 2: The Meat
The zone of proximal development (ZPD) is the learning gap between what a student can achieve problem-solving on his/her own and what the learner can yet achieve with interactive educational support from one who has already mastered a skill or concept, a more knowledgeable other (MKO).2 The relationship between student and “teacher” is active and collaborative.
Vygotsky arrived at the theory of ZPD through his interest in cognitive growth and development in children and how to best measure intelligence. He believed that social interaction and communication influence and foster cognitive development. Comparing a child’s independent problem-solving ability with their ability to problem-solve when assisted by a more knowledgeable teacher of the concept or skill assesses their intelligence. Therefore, a zone of proximal development promotes the idea that cognitive growth occurs when there is an interactive exchange between a learner and a more proficient person – an adult teacher, a parent, a near-peer or peer who has already understood and mastered the concept or skill – that is, a MKO. The interaction between the MKO and the student impacts not only the process but also the cognitive outcome in the learner.2
The interactive educational support provided by a teacher, near-peer, or peer who is proficient in the skill or understands the concept well is known as scaffolding. The MKO helps the learner to build on and apply their basic understanding of the concept or skill.2 In other words, the MKO provides educational scaffolding to help the learner reach the next level of knowledge or skill. The MKO uses scaffolding by giving explicit learning objectives, rationale, other verbal and non-verbal communication, a variety of types of modeling (role, problem-solving, skill building), motivation, de-construction of the concept or skill, and/or direct instruction. As with the use of scaffolding in the construction of a building, over time, the learner will need less and less support or scaffolding to stand on their own and expand knowledge to new levels and thus expand the ZPD. The ultimate goal of this process is to develop and promote skills and responsibility for independent lifelong learning.
The relevance for medical education and the integral role and benefits that these educational concepts play in developing curricula for undergraduate and graduate physicians-in-training are compelling. Millennial cohorts of learners have a robust need for frequent feedback for their skill and concept development.3 Furthermore, studies also show that students achieve higher cognitive integration of foundational science concepts with clinical skills through activities where educators make explicit purposeful connections to students, also requiring more faculty time.4 Therefore, the incorporation of more and more teaching modalities utilizing ZPD and scaffolding principles poses an ever-increasing burden on medical school faculty resources.
The principle of a ZPD is also at the very heart of the Association of American Medical College’s recent CEPAER guidelines (Core Entrustable Professional Activities Entering Residency) to help medical students better prepare to transition to residency. The EPAs guide medical educators and students to the ZPD that they must bridge to achieve the competency levels necessary to enter residency training. Furthermore, a significant contribution to the education of physicians is the ubiquitous yet formalized vertical teaching done by near peer medical students and residents that are more senior in training than the learner. In some institutions, peer teaching and peer feedback activities help in their training. Consequently, using the ZPD and scaffolding approaches (relying on a MKO) to implement medical education ultimately requires that every physician-in-training needs to be taught not only how to learn, but also how to teach!
Modern takes or advances
In the latter 20th century Vygotsky’s principle of the zone of proximal development has benefitted by being extended to consider the cognitive development of adults – from young through mature professionals in training – in a diverse range of professional contexts. Wass et al. describe a cohort of junior zoology students’ insightful comments about their journeys through the ZPD, in which the subjects themselves evolve to acknowledge the benefit of social learning; in fact, they even request a more challenging scaffolding in the form of critical thinking exercises and research.5 Dunphy and Dunphy align the ZPD conceptual framework with the training of obstetrical surgeons, outlining four key stages of learning evolution within the ZPD and applying them to specific stages in a surgeon’s development: acquisition of psychomotor skills, first on non-human models then on patients with direct supervision (Stages 1 and 2, the handover and self-assisted stages); an automatized Stage 3, wherein one’s skills are largely unconscious and where most professionals will spend the bulk of their careers; and Stage 4, in which a new challenge forces the expert to return to their ZPD and cultivate the skill of lifelong learning.6 In this way, Vygotsky’s concept supports the idea of the continuing education required by many professional boards and societies– the ZPD is dynamic and will wax and wane throughout one’s career.
Other examples of where this theory might apply in both the classroom & clinical setting
The ZPD concept, with its components of the MKO, scaffolding, and reciprocal interaction, has been incorporated into multiple health professions education techniques over the last several decades. These include problem-based learning, team-based learning, simulation, and usage of standardized patients in a group learning setting; all of these modalities utilize the learner’s peers as a vital component of scaffolding. Two specific examples of teaching modalities for classroom and clinical teaching include the Intern Bootcamp, used during the latter stages of undergraduate medical education, and simulation-based learning.
The Intern Bootcamp is an activity designed to provide 4th-year medical students with an opportunity to hone their skills before matriculation into residency training. A number of practice activities may be included, including note writing, calling consultants and procedural familiarity. Procedural training serves as an excellent example of where to use the ZPD. Given that the Intern Boot Camp occurs only months before medical school graduation, students have an invested interest in the idea that the information is pertinent and learner engagement tends to be high. Students are situated in small groups with peers of differing specialty choices to diversify the pairings further and then given an instructor who oversees the activity. As a means of scaffolding, students use literature, video explanations of the procedure, and the group meets for a short didactic session before using high-fidelity simulation models to practice the procedure. The instructor provides a brief narrative to the group with questioning, to better assess the learner’s baseline level of knowledge and then progresses to the model and equipment necessary for the procedure. The group uses the opportunity to complete the entire procedure individually with cues from classmates and faculty concerning preparation and competency. This activity is one that piques the interest of the student and cues self-awareness of their preparedness about their upcoming responsibilities as a resident physician. Additionally, this activity will further garner interest in further reading or practice if there is a notable deficiency.
Another example of clinically applicable teaching occurs with high-fidelity simulation activities. Learners are grouped together, designate tasks and try to apply their baseline knowledge to a problem-based case. Scaffolding may include pre-learning or post-learning materials, and the interplay between learners throughout the case serves as a means for social constructivism. Feedback is provided immediately after that and serves as an excellent venue to summarize learning objectives, provide personal reflection, and further sharing of knowledge and experience among learners.
Annotated Bibliography of Key Papers
Dunphy BC, Dunphy SL. Assisted Performance and the Zone of Proximal Development (ZPD); a Potential Framework for Providing Surgical Education. Austral Jour Educ Dev Psychol 2003;3:48-58.
This article from obstetric surgeons addresses the concept of “assisted performance,” which is what the learner can do with help from anything in his or her environment, including instructors, peers, and materials.6 The authors describe the ZPD as the space between assisted and unassisted performance and task the educator with bringing the learner across this chiasm, with instruction carefully catered to the learner’s current stage of development. They discuss four stages of learning within a student’s ZPD: 1) Handover stage, in which the teacher gradually surrenders control to the learner; 2) Self-assisted stage, in which the learner can function independently of the teacher, but still requires constant self-regulation; 3) Automatic stage, in which the learner performs tasks subconsciously and without self-regulation; and 4) Lifelong learning stage, in which skills become de-automatized and the expert tumbles back down into the ZPD to acquire new skills. The authors describe six types of assisted performance to help move learners through these stages: modeling, contingency management (rewards or punishments following learner behavior), feedback, instructing, questioning, and cognitive structuring. They affirm that an educator must have a “profound knowledge of the subject matter” to effectively assist a learner’s performance and, since formal training in medical education is not ubiquitous for all surgeons, the ZPD can be a helpful framework to think about teaching physician trainees and helping them move from stage to stage.
Sanders D, Welk DS. Strategies to scaffold student learning: applying Vygotsky’s Zone of Proximal Development. Nurse Educ 2005;30(5):203-207.
This article from the nursing field builds on the same concepts as Dunphy and Dunphy, describing the assisted performance as a way of scaffolding student learning and development.7 The authors describe the same four stages of learning and development within the ZPD: 1) performance is “other-assisted” (teacher-directed learning); 2) performance is “self-assisted” (self-directed learning); 3) performance is automatic and self-regulated; and 4) formerly unconscious skills are “de-automized” (as in after significant stressor), and the student falls to an earlier stage of development. The goal of the teacher is to scaffold the learner’s progression through these stages through assisted performance. This article is helpful for educators struggling to establish their role in socially-based learning.
Wass R, Harland T, Mercer A. Scaffolding critical thinking in the zone of proximal development. Higher Educ Research Dev 2011;30(3):317-328.
This article describes a “zone of current development,” where students are currently, and names the ZPD as the next step in learning.5 The zoology graduate students studied by the authors felt that the didactics and written material presented during the first year of school appropriately scaffolded their development of rote knowledge, but did not encourage growth in critical thinking; the students thus felt frustrated because they were not involved in creating their ZPD. As they encountered what the authors call “ZPD 2” as second-year students, they extended their learning into current scientific literature, ultimately designing their research to better engage them in their learning. This article illustrates the usefulness of the ZPD concept in real-life health professions education.
While the ZPD theory is a helpful framework to help educators design curriculum, it does not address how best to establish a ZPD through a needs assessment, check in with students’ progress along the way, or assess for adequate emergence from the ZPD as a more knowledgeable learner. The ZPD attaches a name to something educators know intuitively—the learners know what they know and, with the educator’s assistance, need to progress to a more advanced level of knowledge—but doesn’t necessarily contribute new perspectives on how to help students learn more effectively, or how to evaluate their learning. Furthermore, there is minimal primary data suggesting that a ZPD-based approach improves learning objectively, and most existing literature merely pontificates on the philosophy behind the ZPD.
Part 3: The Denouement
After taking time to review social constructivism and the concept of the ZPD, you generated an idea for a weeklong “Intern Boot Camp” for all of your CCP students. While creating objectives for your Boot Camp, you consult the Entrustable Professional Activities (EPAs) for your institution and attempt to match EPAs with your learning objectives. One of these EPAs is to manage a patient in cardiac arrest according to ACLS (Advanced Cardiac Life Support) guidelines. At the start of the Boot Camp, groups of students will run three low-fidelity simulation cases of cardiac arrest, with one of the students observing and completing a checklist of Critical Actions performed; you and other faculty members will circulate amongst the groups, assisting students and correcting errors as needed. After running the cases, the students will reconvene as a large group and discuss the completed checklists, generating a list of skills most of them did well and others that they would like to develop further. Throughout the week of Boot Camp, students will assist each other in refining their resuscitation skills, and, on the last day, each student will again have the opportunity to run a simulated cardiac arrest case, this time without any assistance from faculty.
Anna and Nic are thrilled to see that they will have the opportunity to practice critical care in a low-risk setting before starting internship. After completing their low-fidelity simulation cases and discussing strengths and weaknesses as a group, Anna decides to focus on communication-related skills of task delegation, frequent summaries, speaking loudly and clearly; Nic selects pathophysiology of pulseless electrical activity (PEA) for his learning goal. Recognizing that they have complementary skillsets, Anna and Nic pair up with each other; Nic gives Anna directed feedback on her leadership, and also helps her run through essential steps in management of critically ill patients, such as connecting the patient to the cardiac monitor, placing the patient on oxygen, and obtaining vascular access. Anna refers Nic to a textbook chapter on PEA, and shares her mnemonic for remembering “the H’s and T’s.”
By the end of the week, both students successfully resuscitate a patient according to ACLS guidelines, accomplishing all Critical Actions, without any input from their peers or teachers. At graduation, they both come up to you to thank you for providing the scaffolding for them to achieve this critical EPA.
PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW
1. Badie F. A Theoretical Model for Meaning Construction through Constructivist Concept Learning.
2. Shabani K, Khatib M, Ebadi S. Vygotsky’s Zone of Proximal Development: Instructional Implications and Teachers’ Professional Development. English language teaching. 2010;3(4):237-248.
3. Desy JR, Reed DA, Wolanskyj AP. Milestones and Millennials: A Perfect Pairing—Competency-Based Medical Education and the Learning Preferences of Generation Y. presented at: Mayo Clinic Proceedings 2017.
4. Kulasegaram K, Manzone JC, Ku C, Skye A, Wadey V, Woods NN. Cause and effect: Testing a mechanism and method for the cognitive integration of basic science. Academic Medicine. 2015;90(11):S63-S69.
5. Wass R, Harland T, Mercer A. Scaffolding critical thinking in the zone of proximal development. Higher Education Research & Development. 2011;30(3):317-328.
6. Dunphy BC, Dunphy SL. Assisted performance and the zone of proximal development (ZPD); a potential framework for providing surgical education. Australian Journal of Educational & Developmental Psychology. 2003;3(2003):48-58.
7. Sanders D, Welk DS. Strategies to scaffold student learning: Applying Vygotsky’s zone of proximal development. Nurse educator. 2005;30(5):203-207.