3 Clark RE. Reconsidering researchon learning from media. Rev EducRes 1983;53:445–59.

4 Cook DA. The research we still arenot doing: an agenda for the studyof computer-based learning. AcadMed 2005;80:541–8.

5 Byrnes JP. Cognitive Development andLearning in Instructional Contexts.Boston, MA: Allyn & Bacon1996;73–4.

6 Bransford JD, Brown AL, CockingRR, eds. How People Learn: Brain,

Mind, Experience, and School. Wash-ington, DC: National AcademyPress 2000;51–78.

7 Kalyuga S, Ayres P, Chandler P,Sweller J. The expertise reversaleffect. Educ Psychol 2003;38:23–31.

8 Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberatepractice in the acquisition of expertperformance. Psychol Rev1993;100:363–406.

9 Pintrich PR. A motivational scienceperspective on the role of studentmotivation in learning and teach-ing contexts. J Educ Psychol2003;95:667–86.

10 La Rochelle JS, Durning SJ,Pangaro LN, Artino AR, van derVleuten CPM, Schuwirth LWT.Authenticity of instruction andstudent performance: a prospectiverandomised trial. Med Educ2011;45:807–17.

Medical error: time to get real?Victoria R Tallentire & Samanth E Smith

‘I am indeed amazed when Iconsider how weak my mind isand how prone to error.’Rene Descartes

In recent years, professional guide-lines, legislation and patient safetyinitiatives throughout the devel-oped world have mirrored the pub-lic’s desire for increased disclosureof medical error.1,2 Error training isnow an integral part of many pri-mary medical training programmes,and Varjavand et al.’s study,3

reported in this issue of MedicalEducation, provides cause for cele-bration amongst those who havechampioned such teaching. Thestudy used hypothetical clinicalscenarios to investigate attitudinalchange amongst cohorts of internscommencing professional practice

in 1999–2001 and 2008–2009.3 Theresults demonstrated that the pro-portion of individuals willing to fullydisclose their mistake to the affectedpatient in each of the two scenarios(defined as explaining the error andadmitting fault) in the 2008–2009cohort was almost double that in the1999–2001 cohort.3

However, like all good studies, thiswork raises many more questionsthan it answers. Echoing the resultsof previous research,4 the errordisclosure rate in this study wasinversely proportional to the sever-ity of the consequences for thepatient. In other words, the moresevere the patient’s clinical seque-lae, the less information was likely tobe disclosed. In the 1999–2001cohort, 70% of interns agreed that‘disclosure exposes one to litiga-tion’. This proportion declined inthe 2008–2009 cohort, althoughover half of respondents agreed withthe statement.3 Such a high level oflitigious concern so early in anindividual’s career is disheartening,particularly in light of recent re-search demonstrating that early dis-closure of error may actually reducemalpractice claims.5 However, wider

dissemination of the benefits ofearly disclosure policies is likely tohave little effect on the overallproblem in the presence of muchstronger opposing forces. The atti-tudes and behaviours of all newlyqualified doctors are heavily influ-enced by the prevailing culture ofthe organisation and their percep-tion of the hierarchy within whichthey work.6 Varjavand et al.’s findingthat fewer than half of the interns ineach cohort would discuss an errorwith their attending phyisicians3 willmake sobering reading for thoseultimately responsible for the careof patients. It is the responsibility ofsenior clinicians to confront thischallenge by creating a culture oftrust and openness amongst theircolleagues. They must attend to thepower of role-modelling7 by dis-cussing their own errors, whilst tak-ing care to exemplify the honestyand humility they seek to inculcatein their junior colleagues.

The attitudes and behaviours of all newlyqualified doctors are heavily influenced

by the prevailing culture of theorganisation

Centre for Medical Education, University ofEdinburgh, Edinburgh, UK

Correspondence: Victoria R Tallentire, Centrefor Medical Education, University ofEdinburgh, Chancellor’s Building, 49 LittleFrance Crescent, Little France, EdinburghEH16 4SB, UK. Tel: 00 44 131 242 6368;Fax: 00 44 131 242 6380;E-mail: Vicky.Tallentire@ed.ac.uk

doi: 10.1111/j.1365-2923.2012.04292.x

632 ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 630–635

commentaries

However, perhaps the most inter-esting finding in Varjavand et al.’sstudy3 is that prior training inmedical mistakes was found tohave no effect on the rate of fulldisclosure in either cohort. Asmedical educationalists, we areforced to reflect on this further:can it really be possible that train-ing which presumably emphasisesthe ethical and professionalobligations relating to disclosure oferror has no demonstrable influ-ence whatsoever on subsequentbehaviour?

Can it really be possible that training inerror disclosure has no demonstrableinfluence whatsoever on subsequent

behaviour?

The importance of such a findingcannot be overstated, for itembodies the fundamental chal-lenge of medical education. Inrelation to the development ofattitudes and behaviours, idealisticand sterile classroom teaching isoften cast aside when newly quali-fied doctors are faced with thecomplexities and pressures of theworkplace.6,8 On hospital wardsthroughout the world, newly quali-fied doctors grapple with their newroles, eager to outshine their peers,impress colleagues and appeasepatients. What seemed in the class-room to be the sound course ofaction suddenly becomes toohumiliating to consider as a realisticoption. Having entered what isconsidered to be a team-based pro-fession, a newly qualified doctormay feel absolutely alone on the dayhe or she first makes their firstserious error.

Idealistic classroom teaching is often castaside when newly qualified doctors are

faced with the complexities and pressuresof the workplace

How should we, the medical edu-cation community, respond to theproblem of workplace culture andpersonal protectionism trumpingthe ethical principles and practiceswe so diligently teach our students?Perhaps a part of the solutioninvolves exposing students to mak-ing clinical errors or, at least, to thepossibility of making such errors inways that are more indelible thanthe hypothetical scenarios theyencounter in classroom environ-ments. Are we, through concern forpatient safety, depriving students ofopportunities to gain insights intothe complex reality of clinicalpractice and develop the values andattitudes that will facilitate fullerdisclosure of medical errors as theircareers progress? Allowing studentssome scope for error will permitthem, for perhaps the first time intheir lives, to come face-to-face withtheir own fallibility.

Allowing students some scope for errorwill permit them to come face-to-face with

their own fallibility

Although exposure to personalerror may be emotionally andpsychologically difficult, asystematic review of studiesexamining doctors’ experiences oferror has shown that personal errormay also be positive, enhancingboth doctors’ confidence and theirprofessional relationships.9 Medicaltrainees typically feel that theylearn the most from their ownmistakes.10 Is it therefore time tomove away from attempting toteach students about error bydiscussing the mistakes of others orusing hypothetical scenarios? Thechallenge for medical educational-ists is to seek ways in which toexpose students to opportunitiesfor error, whilst developing safe-guards that adequately protect pa-tients. It is through personalexperience that our students will

develop acceptance of their ownfallibility, foster the resilience theyneed to continue to practise, andtruly learn that disclosing andapologising for error is not only aprofessional responsibility, but alsoa personal strength.

Disclosing and apologising for error is notonly a professional responsibility, it is

also a personal strength

REFERENCES

1 Mazor KM, Simon SR, Gurwitz JH.Communicating with patientsabout medical errors: a review ofthe literature. Arch Intern Med2004;164 (15):1690–7.

2 Kalra J, Massey KL, Mulla A. Dis-closure of medical error: policiesand practice. J R Soc Med 2005;98(7):307–9.

3 Varjavand N, Bachegowda LS,Gracely E, Novack DH. Changesin intern attitudes toward medicalerror and disclosure. Med Educ2012;46:668–77.

4 Sweet MP, Bernat JL. A study of theethical duty of physicians to dis-close errors. J Clin Ethics 1997;8(4):341–8.

5 University of Michigan HealthSystem. Medical malpractice andpatient safety at UMHS. Ann Arbor,MI: UMHS. http://www.med.umich.edu/news/newsroom/mm.htm. [Accessed 12 March2012.]

6 Tallentire VR, Smith SE, Skinner J,Cameron HS. Understanding thebehaviour of newly qualified doc-tors in acute care contexts. MedEduc 2011;45 (10):995–1005.

7 Shuval JT, Adler I. The role ofmodels in professional socialisa-tion. Soc Sci Med 1980;14A (1):5–14.

8 Dornan T, Ashcroft D, HeathfieldH, Lewis P, Miles J, Taylor D, TullyM, Wass V. An in-depth investiga-tion into causes of prescribing er-rors by foundation trainees inrelation to their medical education:EQUIP study. 2009. http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf. [Accessed 12March 2012.]

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9 Sirriyeh R, Lawton R, Gardner P,Armitage G. Coping with medicalerror: a systematic review of papersto assess the effects of involvementin medical errors on healthcare

professionals’ psychological well-being. Qual Saf Health Care 2010;19(6):43.

10 Fischer MA, Mazor KM, Baril J,Alper E, DeMarco D, Pugnaire

M. Learning from mistakes. Factorsthat influence how students andresidents learn from medicalerrors. J Gen Intern Med 2006;21(5):419–23.

Learning styles: where’s the evidence?Doug Rohrer1 & Harold Pashler2

Whereas modern medicine owesmuch of its success to its relianceupon evidence-based treatments,most popular techniques ofinstruction have not been subjectedto thorough empirical scrutiny. Aparticularly glaring and costly resultof this, we argue, is the wide accep-tance of the idea that instructionshould be tailored to a student’s so-called learning style. For example,students might be divided intovisual learners and verbal learners(on the basis of a learning style testgiven to each student) and thenprovided with instruction that em-phasises pictures or words, respec-tively. The visual–verbal distinctionis only one simple example of themany proposed taxonomies; a re-cent review described 71 differentschemes.1 Given this advocacy byacademics and the ensuing heartfeltpraise of educators, tailoringinstruction to students’ style is nowa prevalent and profitable enter-prise. However, as we and othershave pointed out,2–5 a thoughtfulreview of the data provides no sup-port for style-based instruction.

Whereas modern medicine owes much ofits success to evidence-based treatments,most instructional techniques have not

been subjected to empirical scrutiny

At first blush, style-based instructionseems to be supported by a largeempirical literature. However, clo-ser examination reveals that only asmall portion of these studies usethe only research design capable ofsupporting the idea that customisedinstruction produces better learningthan using the same kind ofinstruction for everyone.4–6 Toillustrate the appropriate design andthe kind of result needed to showsupport for style-based instruction,we describe a hypothetical study ofthe visual–verbal taxonomy. Firstly,subjects are divided into visuallearners and verbal learners on thebasis of some sort of learning stylestest (usually a questionnaire). Sec-ondly, all subjects, regardless oftheir assessed style, must be ran-domly assigned to receive eitherinstruction tailored to visual learn-ers or instruction tailored to verballearners. Notably, this means thathalf of the visual learners and half ofthe verbal learners will receive the‘right’ kind of instruction, and theother half of each group will receivethe ‘wrong’ kind of instruction.Finally, all subjects must be given thesame test of learning. The results ofsuch a study would support style-based instruction if and only if thetest scores revealed two findings:

visual learners do better if instruc-tion is visual rather than verbal, andverbal learners do better if instruc-tion is verbal rather than visual. Ifthese two findings are not observed,it means that both kinds of learnersdid better with the same kind ofinstruction, which is a negativefinding.

At first blush, style-based instructionseems to be supported by a large empirical

literature.

Our search of the extensive litera-ture on learning styles, which in-cluded written inquiries to prolificadvocates of style-based instruction,revealed that the appropriatedesign was used in only about 20studies, and the results of most ofthem are compellingly negative.These negative findings wereobtained with a variety of learningmaterials, including some in sci-ence6 and medicine.7 By contrast,we are aware of only three appro-priately designed studies thatyielded a positive finding like thatdescribed in our hypotheticalexample, and these findings are notvery convincing. In one case, nomeasures of the data were pro-vided, and the authors reportedthat only one of three studies of thesame intervention produced astatistically significant finding.8 Inanother study reporting a positivefinding, only one of the two finaltests revealed a benefit of

1Tampa, Florida, USA2La Jolla, California, USA

Correspondence: Doug Rohrer, Department ofPsychology, PCD 4118G, University of SouthFlorida, Tampa, Florida 33620, USA.Tel: 813 974 0364; E-mail: drohrer@usf.edu

doi: 10.1111/j.1365-2923.2012.04273.x

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