This latter point applies to the context of medical education, where a recent commission (Frenk et al., 2010) has highlighted the increasingly complex challenges currently facing health care, and by association, its educators, concluding that educational reforms should result in transformative learning. While medical education must produce leaders capable of positively impacting their field of interest, I disagree that such transformative education should be considered the sole outcome. Rather, I think that this commission’s proposed instructional reforms to medical education involve the artificial distinctions between so-called informative, formative, and transformative learning. Each of these goals should simultaneously be addressed by medical education, as they build upon one another. It is thus guilty, in my opinion, of de-emphasizing the importance of developing physicians as medical experts and professionals.

 

My opinion as to the purpose of adult education, and by extension, medical education, is further understood by exploring both my conceptualization of the differences between adult learners, and my worldview in analyzing human needs, two additional questions worthy of reflection in the formulation of an adult educational philosophy (Tisdell & Taylor, 2000).

 

Adult learners differ in countless ways, most notably in their context-specific knowledge and skills, experiences, and aptitudes, which influence their strengths and weaknesses, and their beliefs, experiences, and interests, which shape their motivations, attitudes, values, and needs within a given learning environment and curriculum. Furthermore, mature learners may face social and cultural constraints based on their position in society (MacGrath, 1999), as well as time constraints given the other roles they assume beyond the educational institution. Last, and not to be forgotten, individual philosophic differences and learning preferences may lead to differing and even opposing perceptions of a shared educational experience. Adults may be more aware and able to articulate these unique components of their identity. They may also be able to identify their strengths and interests, not just within the different fields of medicine, but within its practice. This is ultimately why I believe that the purpose of medical education should not be to uniformly “produce enlightened change agents” (Frenk  et al., 2010, p. 1924); rather, it should be to prepare learners for a multitude of roles, and to help them identify those that they are likely to enjoy and excel at, so these can be further supported in addition to core competencies.

 

The purpose of medical education can therefore be generalized, being conceptually equivalent to learner self-actualization, which, on the basis of my humanistic worldview of human needs centered around Maslow’s hierarchy, is the ultimate means of self-fulfillment. I believe that education can be central to addressing each level of human need on this hierarchy, for any learner, in any situation. At a basic level, education addresses physiological and safety needs, wherein its goals are more pragmatic and utilitarian. At another level, paying equal attention to affective and cognitive dimensions (Price, 2000) enables learners to satisfy humanistic needs for belonging and esteem. Broader still, promoting self-concept and the development of the fullest potential inherent to every student (Ellias & Merriam, 2005), based on an existential concern for human freedom and integrity, optimizes individual learning and subsequent contribution to society because of improved self-awareness guiding learners in current and future pursuits. So, while I acknowledge that core competencies or objectives of learning are necessary outcomes of health education, they should not be limited to these alone.

 

But education should also be viewed as a privilege for both teachers and learners, as I have alluded to, and so this need for education is accompanied by an assumption that each party will fulfill its roles. Defining these roles is inextricably accompanied by questions about the process of knowledge acquisition and justification as well as the relationship between teachers and learners, all of which require an exploration of epistemological and ontological assumptions.

 

My educational philosophy is predicated on constructivist assumptions, which emphasizes individual experience and reflection in creating meaning, allowing for both empirical and rational knowledge acquisition. Thus, students should utilize their unique set of accumulated experiences to participate in learning, by analyzing these experiences to make sense of the material (McGrath, 1999). By a similar view, the student should be an active participant, willing to engage with others in collaborative and cooperative efforts towards discovery and problem-based learning.

 

Constructivism is also consistent with fallibilism, whereby both learners and teachers should acknowledge the possibility that beliefs can be contradicted by new arguments and experiences, and thus be subsequently revised or withdrawn. This has become increasingly important in medicine in the 21st century, where an “explosive growth of knowledge and technologies” (Frenk et al., 2010, p. 1926) has led to rapid turnover of what ideas are viewed as most accurate or what constitutes best practice. Thus, both students and teachers should assume the roles of philosophers. As part of education, both should continually engage in “questions about what we do and why we do it” (Elias & Merriam, 2005, p. 5). This allows one to arrive at one’s own conclusions about whether or not a theory and practice will be accepted and/or criticized, and should hopefully drive the individual who is not satisfied to seek out alternatives. An adult learner should understandably use these questions to clarify knowledge and values, and all learners should ask such questions to fuel their inquisitive nature and love of learning.

 

Although the acceptance of fallibilism demands awareness and acceptance of developing knowledge, former knowledge does not have to be abandoned. Therefore, it is still appropriate for a humanist learner to strive for an intellectual education, drawing upon the liberal-proposed pursuit of practical wisdom. Learners should push beyond the acquisition of information, and aim for a systematic and organized grasp of a subject that can be communicated to others, with the ultimate goal of practically applying the knowledge of this material to the problem or situation at hand in order to possess wisdom (Ellias & Merriam, 2005). This quest applied to medical education requires that students also assume the role of an educator, which requires the “searching, analysis, and synthesis of information for decision making” (Frenk et al., 2010, p. 1924), followed by communication and collaboration with other students in solving relevant problems. Becoming an educator involves multiple competencies and is deemed by some, myself included, to be an ultimate goal of medical education, as it signifies that the student has demonstrated a commitment to maintaining expertise and taking ownership of self-assessment and self-improvement, as well as leadership in teaching and learning (Pangaro, 1999).

 

The essence of such a commitment outlines the role of a self-directed learner, based on existential principles of human self-determinism and the associated responsibility entrusted to individuals to make choices, and be responsible for the outcomes of these choices, in spite of the external forces and internal urges that may threaten autonomy (Ellias & Merriam, 2005). A self-directed learner also defines what I perceive to be the most distinct role for an adult learner. Much as we expect children to reach psychological and social maturity and independence as they reach adulthood, so too should we expect it from adult learners. However, learners who are adults should not be expected to swim after being thrown “into the strange waters of self-directed learning” (Knowles, 1989, p. 47), especially when the content of education itself is strange. Rather, as an adult student develops an increasingly independent self-concept and internal motivation, his or her role in the educational process is to become self-directed, which includes the self-diagnosis of learning needs, self-directed inquiry, and self-evaluation of learning (McGrath, 1999). 

 

Based on these expectations, the role of the teacher becomes clearer. An educator can help the student assume these roles by providing affective support, through the creation of a cooperative, reassuring learning environment, promotion of a positive self-concept among students, and maintenance of respect for learner autonomy. In particular, an educator should facilitate self-directed learning by aiding the learner in identifying individual goals, assisting in identifying relevant resources for inquiry, and acting as a flexible resource to the group, in order to promote increased independence and direction from students as their experience progresses within a given context. However, while the teacher promotes autonomy amongst his or her students, he or she actually enters into a relationship with them, based on mutual respect and trust. Just as the learner must aim to assume a teaching role, so too must the teacher assume the role of a learner and a participant in the class, by sharing authentic experiences while helping students make meaning of their own, and by promoting student dialogue and democratic participation. As Knowles (1989, p. 12) has acknowledged, “none but the humble become good teachers of adults.”