The cognitive apprenticeship: advancing reasoning education by thinking aloud

Introduction

Though skilled in the art of diagnosis and management, medical educators may struggle to teach clinical reasoning when they are unfamiliar with core reasoning concepts, have limited experience describing their reasoning, or feel vulnerable exposing knowledge gaps or clinical uncertainty. When teachers are uncomfortable verbalizing or analyzing their own reasoning, they may default to the more familiar and concrete transmission of medical knowledge. Broadcasting cognition instead of knowledge entails the educator reimagining their relationship with learners as a cognitive apprenticeship.

Making the invisible visible

Unlike a traditional apprenticeship where visuospatial and tactile skills are overt – e.g., the novice observing the expert butcher cutting meat – many elements of clinical practice, such as clinical reasoning, are invisible. Without access to the cognitive processes behind how an experienced clinician makes a specific decision, learners may “fill in the blanks” and develop inaccurate explanations or mental models which inform their future reasoning. Teachers of reasoning can engage learners in a cognitive apprenticeship to illuminate these frequently tacit processes.

Cognitive apprenticeship is an instructional strategy that emphasizes teachers externalizing their thought processes by thinking aloud [1], [2], [3], [4]. Teachers may feel comfortable thinking aloud in familiar or straightforward clinical scenarios they can approach with dexterity. However, when teachers reserve this technique for only their most polished cognition, they convey an inaccurate and unrealistic picture of the day-to-day practice that learners are preparing for.

Bearman and Molloy coined the term “intellectual streaking” to describe teachers narrating their thought processes through uncertainties, difficulties, and failures in professional practice [5]. Just as an individual removes their clothes when they engage in streaking (popular depictions include a sports fan running across the field naked), teachers can metaphorically expose themselves when their experience or knowledge feels flimsy.

Deliberate engagement in intellectual streaking serves several important functions for the learner [6], [7], [8], [9], [10], [11]:

1. Normalizes uncertainty in clinical reasoning: by showing learners thought processes that are not airbrushed, teachers demonstrate how to embody a growth mindset and learn from uncertainty or mistakes [12, 13]. This modeling can convey that vulnerable moments are features, not flaws, of the learning process and clinical care.

2. Provides a realistic goal for learners: in revealing their struggles, teachers demonstrate that expertise is not the absence of uncertainty, but rather the ability to make sound decisions in the face of it.

3. Levels the playing field: sharing vulnerability can augment the learning process and improve the teacher-learner relationship by flattening the hierarchy of clinical education and reducing the teacher’s psychological size [14, 15]. As a result, learners may feel more comfortable narrating their cognition, which enhances teachers’ ability to assess reasoning skills and identify growth opportunities.

What thinking aloud sounds like

The following examples demonstrate clinical scenarios where a teacher can shift from the transmission of facts and data to a conversation where thinking rather than knowledge is the main catalyst for instruction.

Spreading the word

The development of teachers and educational programs with strong cultures of thinking aloud will require individual, institutional, and systemic initiatives.

Individual educators should identify situations where sharing their thought process for arriving at or rejecting a diagnosis or explaining their uncertainty would add greater value than sharing facts or asking questions [17]. Similarly, they should give feedback on their learners’ ability to explain their thinking to consultants, interprofessional colleagues, or patients and families.

Training programs should ensure that all teachers can adopt the cognitive apprenticeship model through faculty development. These initiatives should teach the terminology of clinical reasoning, use cases to give teachers experience narrating their thinking, and provide exercises to practice intellectual streaking [18]. Programs can shift their conferences from pre-planned cases with tidy final diagnoses to unscripted case conferences where residents and faculty are forced to struggle with the uncertainty [19, 20]. Establishing a culture of psychological safety within a training program can encourage learners to think aloud, intellectually streak, and disclose errors with their peers.

National organizations have called for the advancement of clinical reasoning education using competencies for both learners and educators [21, 22]. In developing examples and supporting materials, these organizations should highlight how the cognitive apprenticeship model and intellectual streaking could enhance reasoning education.

Conclusions

Many professions – from mathematics teachers to nurse educators to military instructors – have demonstrated how thinking aloud and intellectual streaking accelerate novices’ reasoning skills and comfort with uncertainty [23–26]. Research is needed to examine how teachers apply these same strategies in the clinical environment and how they impact learners’ reasoning processes.

The quest to become more skilled at thinking aloud is not just an academic pursuit. Bringing this skill to our everyday interactions with learners, colleagues, and patients can bring transparency to the diagnostic process and management planning that fosters understanding and collaboration.