Public Health (1991), 105, 39 50

© The Society of Public Health, 1991

Courses of A c t i o n - - t h e Case for Experiential Learning Programmes in Public Health John

Gabbay

Academic Department of Public Health, St Mary's Hospital Medical School University of London, Praed Street, London W2 1PG

All at Sea with the Old Educational Model 'Good navigation can be achieved only by experience. Imaginary passages, worked on the dining-room table, help to build up speed and proficiency in chart-work, but they cannot be a substitute for practice at sea... Practice does not make the waves any smaller, the driving spray less penetrating or the motion less violent, but it teaches the navigator to come to terms with the problems which are a part of sea-going in yachts. The art of steadying a gyrating hand-bearing compass, finding a comfortable working position at a chart-table heeled to an angle of 45° and estimating the amount to steer to windward on a reach.., cannot be taught by lecturers or writers, only by the sea.'~ Public health physicians have had a r o u g h passage? The 1974 re-organisation, 3 the 1982 re-organisation, the Griffiths report, 4 the A c h e s o n I n q u i r y 5 and n o w the N H S Review 6 are only the more obvious manifestations o f the continual harsh winds, unpredictable currents, crashing waves and dense N H S fog for which we must be trained. The skills for such conditions c a n n o t be taught by lecturers, writers and theoretical courses d r a w n on dining r o o m - - o r rather c l a s s r o o o m - - t a b l e s . But h o w can we best learn f r o m being on the sea? There is, after all, a limit to w h a t we learn while being tossed a r o u n d the cabin deck as we head for the rocks. Effective professional training requires m o r e than classroom theory and practical experience; it requires the integration o f both. It is that elusive link which public health physicians need to develop, and which I shall explore here. In 1981 Alwyn Smith wrote a splendid critique o f the long-established traditions o f medical education, 7 in which he stressed the irrationality o f a course in which medical students only understand medicine when they acquire their practical experience after graduation. 'There are m a n y powerful arguments', he wrote, ' f o r combining theoretical learning with practical experience so that the two m o d e s o f learning m a y mutually reinforce each other and provide a cross-fertilisation o f insights.'

Learning from lectures Lectures certainly frustrated me at medical school, and none m o r e so than his. W h e n they were full o f useful facts, I would have preferred to read them, n o t scribble frantically. W h e n they were giving a conceptual framework, I m i s t o o k it for waffle. W h e n they tried to stimulate me to think, I c o u l d n ' t - - n o t whilst having to listen and write at the same time. W h e n they tried, even successfully, to change m y prejudiced attitudes, then they would soon be outweighed by other influences. A n d if they might have been relevant to my future p r a c t i c e - - w h i c h I could never t e l l - - I knew I would have forgotten them by then. There is ample evidence 8 that even g o o d lectures fail to p r o m o t e thought, change attitudes, or impart skills. Very occasionally they inspire enthusiasm, but in general their

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one useful function is to purvey information efficiently. Even this is equally, if not better achieved, by reading, audiovisual presentation, programmed learning, or open learning. However good such didactic teaching (and it may be excellent) it can, paradoxically, undermine effective learning. People get used to being taught, rather than learning for themselves. They adopt the role of blank sheets to be filled in by a hierarchy of experts with true answers. They become used to covering a syllabus, rather than identifying what they need to know. When their knowledge inevitably becomes obsolete, they are poorly equipped to adapt because they have not developed the ability to build on their own experiences. They are encouraged to stifle mistakes, not learn from them. In short, conventional teaching methods undermine people's natural capacity to shape their learning around their own need to perform better. 9 Such an educational outcome is of limited value in the perplexing, changing world o f public health practice. How useful are classroom methods for public health physicians, when we are such a diverse group fulfilling a wide variety of functions with disparate knowledge and skills? We each come with different prior experience, and each is inclined towards a different blend of public health practice. 5,m~,~2 Our knowledge must span pure and applied, hard and soft sciences, from epidemiology to ethnography, from mathematical modelling to management. Our Faculty's recent annual Training Conferences have left little doubt that whatever function public health physicians undertake, from health promotion to outbreak control, from needs assessment to service evaluation, we require a wide range of skills (Figure 1). The 'knowledge base', along with the theory of the 'technical skills', is well developed and forms the staple fare of our written professional examination. We can acquire such bodies o f knowledge tolerably well in the classroom, given the limitations of traditional pedagogy. But even within these areas--let alone the 'people', 'self management' and other skills--there is much that will never be acquired in the classroom. The consequences are therefore not surprising. When we go out into the world we find it impossible to reconcile our pristine classroom knowledge with the mundane and the hurly-burly of service work. We find that g o o d epidemiological work is usually not feasible, and is in any case overwhelmed by health service practicalities. So we either complain that we are becoming de-skilled by the continued compromises we must make, or we deride academic departments for being out o f touch with reality, while they in turn disdain the intellectual corruption of the 'quick and dirty' service projects. In short, our academic programmes exacerbate the gulf between theory and practice, and thereby undermine both. It would be better to find some way of linking them more closely.

Learning Theory from Practice: the New Model

Experiential learning Kolb and his colleagues have been influential in demonstrating the benefits of re-structuring higher professional training in ways that explicitly link theory and practice. ~3'~4'~5 Knowles has contrasted 'pedagogy'--intended, as the term suggests, for children--with a new term 'andragogy' (which, since it is not just men who learn, presumably also entails gynagogy!). Andragogy is an educational approach that treats the learner as an adult and stresses the pivotal role of the learner's own experience as a source of knowledge. ~6,~7In the terms of Transactional Analysis, the relationship between teacher and learner shifts from parent/child to adult/adult] 8 This style of education t9 has also been influenced by the T group movement and those such as Carl Rogers which, in their

Courses of Action Self Management Attitudes Beliefs Values Prejudices Self confidence Self esteem Integrity Stamina

People Skills Communication Conflict management Leadership Decision Teamwork

making

Technical Skills Information technology methods Financial management

\I~,'~[ iiii~i Planning /~I

Vision Time-management Creativity Flexibility Stress management Energy People reading

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Knowledge Base Medicine Epidemiology Statistics Health economics Organisation theory Management theory Medical sociology Behavioural sciences

I

Political Skills Understanding the system Vested interests Power bases Timing of interventions

Wisdom Experience Judgment Sensitivity (With acknowledgments to Frada Eskin, who developed this model while Director of the Centre for Professional Development, part of Alwyn Smith's Department of Community Medicine, at the University of Manchester Medical School.)

Figure 1 Skills for public health physicians.

quintessentially Californian w a y , 2°'21 have urged the human side of personal development through the shared group experience, in what one observer has wryly caricatured as 'warmly humanistic facilitation of learning in w h i c h . . , teacher and learner grow together in a satisfying, joyous, and bountiful release of latent learning potential. '= More pragmatically British approaches include Reg Revans, 23"24who has been expounding the virtues of what he calls 'action learning' for over 40 years, and the work of the Further Education Unit and Professional Industrial and Commercial Updating (PICKUP), 25 as well as many of the new approaches to management education. 26 This major shift in continuing education methods has been dubbed 'experiential' or 'reflective' learning. It is now being applied in a wide range of adult learning including further education, higher education, personal development, and community development, but many of the reports come from undergraduate, graduate, professional or managerial education. It is not possible in a brief review to do justice to this rapidly growing field. I shall, however, try to give an overview of the insights and ideas the experiential learning movement might lend our own professional education, before I go on to discuss some of the possible objections to experiential learning, and finally suggest some ways forward.

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Experiential learning assumes that people do not learn very well from being given the answers to questions they don't have; they learn better by actively seeking the knowledge they need to solve their problems. Only the learners themselves can judge from their experience what they need to know, and how it matches their career goals and personal aspirations. They are then more likely to accept the relevance of what they learn, and to evaluate it, use it, and retain it. In experiential learning, therefore, the imperative is not merely to cover a set curriculum. It is to help learners acquire the theory, knowledge and competences indicated by their personal (and emotional) needs in response to the practical realities of their workplace. The curriculum is negotiable such that the 'teacher' helps the learner make the right individual choices about what to learn and how to learn it. The learning cycle Experiential learning recognises the simple fact that different people learn in different ways. Kolb 13 has described four main learning styles that involve either abstract thinking, concrete experience, reflective observation, or active experimentation. We may prefer to learn a subject by, say, reading it up, or trying it out, or watching someone and then thinking about the implications, and so on. Not only do we have our personal tendencies, but our specialised education, our chosen profession and the demands of our current job all influence our preferred style. For example, managers, doctors, and scientists have been shown to display significantly different distributions of learning styles which diverge further as they progress through university] 7 Although we may lean towards one or another of these styles, we need to be able to adapt to the many circumstances in which we find ourselves having to learn--especially in a profession as multifarious as public health medicine. If Kolb's model is right, the diversity of learning styles should be encouraged because fixed, limited learning styles are a liability in a changing world. Such diversity can be nurtured or stifled by the educational policies of the organisations in which we study and work. Kolb has found that to learn anything well, we go through a cycle that involves all four of the learning styles (Figure 2). This is because, as Piaget, Argyris, Schon and others have shown, ~3'28learning is not so much a matter of acquiring new knowledge, as of modifying the old. There are few things on which we don't already have some notion, however misguided, before we start. We therefore go through a continuing process of integrating concepts and experiences through what Kolb calls the transformations of experimentation and observation. Or, to put it more simply, we come to understand new ideas or activities by reflecting on them or applying them in practice. And the more we do that, the better we understand them. If we read something that appeals, we try it out. If we undergo some interesting new experience, we ponder it, we find out more about it, we deliberate on what we have found out, we modify how we tackle the experience next time, and so on . . . Otherwise we neither learn from our experience nor turn new knowledge into better practice. I claimed at the outset that we don't learn just by doing, any more than just by being given new facts or ~deas; that we don't learn navigation from the sea or from the classroom, but from integrating the two. The learning cycle provides the key to that elusive link between theory and practice. To exploit it for public health training, we need educational methods that build effective reflection and experimentation into the currently too separate worlds of academic and service training. By reflection I mean the deliberate evaluation o f experience, so as to synthesise it with prior learning, in order to guide the acquisition o f new learning, which includes further experience as well as further tutelage. Such reflection, based

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Abstract L conceptualisationl~

Acti vementatio~n experi

[ observati Reflectiveon

~'~-~[ Concrete experience Figure 2 Kolb's learning cycle.

on a wide range of techniques, is becoming the basis of many courses across a wide range of professions, including a few isolated medical courses. 29,3°

Action learning--the essential tetrad The practical experiences that form so much of public health teaching (statistical exercises, role plays, simulations, or games) rarely meet the criteria of reflective or experiential learning as just defined. They are the equivalent of plotting courses on the dining-room table. Although crucial adjuncts to didactic teaching, they rarely take the student systematically and repeatedly through the whole learning cycle. Neither do they entail reflection on real-world experience. Moreover they suffer the major limitation of not being grounded in the world outside the classroom, and so are unable to make the demands that real live problems do. According to Revans, exercises 'that have no emotional threat teach only how to work on exercises that have no emotional threat'24 This is an extreme view, since there is an argument for simplifying reality whilst acquiring new techniques; it is advisable not to make one's first sea crossing in a gale. Nevertheless, it's also advisable to have the opportunity to learn by formally reflecting on the ordeal with your tutor when you get back to port. Few o f our in-service training placements allow that to happen in an academic setting. Revans argues that learning has two components: programmed learning, 'P', which can be taught by conventional means, and questioning insight, 'Q', which can't. In Revans' model of action learning groups of (usually) managers are given real problems to solve in the workplace. They work as a team, with the help of a tutor who is there only as a resource and facilitator to help them to acquire the knowledge and techniques ( P + Q) to solve the problems themselves. Because the project, being a real-life one, is necessarily ill-structured, there are no pat answers that anyone could teach them, and the real risks involved ensure that there is no pat, superficial learning either. Ideally this model brings together what we should consider as an essential tetrad: trainees, peers, tutor, and boss. Conventional pedagogy tends to omit at least one of these four. Yet each o f this tetrad has a major contribution to make; and each can learn from the programme. In the better forms of experiential learning all four parties should assess the learner in the work place before formulating the learning programme, and should maintain

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continuing mutual feedback so that the learners, bosses and tutors can against achievement in the workplace, not merely against performance exams. Moreover there is usually a spill-over effect in the workplace, as aren't on the team but are also dealing with the problem get drawn into learn from it.

assess progress in seminars or colleagues who the project and

The educational consequences of experiential learn&g Apart from the immediate educational and practical benefits there are several consequences of this model of learning. The first is to encourage the mixing of different academic disciplines, since nearly all the problems experienced in service work require not only epidemiological but, say, organisational skills. In bringing the academic resources to bear together on these joint goals, one is likely to find new connections that will enrich both the epidemiological and organisational theorists of public health. It is not what we learn but how we learn to learn that has the longest effects. After all, the knowledge acquired at the beginning of one's career has a limited shelf life. As Revans trenchantly claims, conventional courses teach yesterday's knowledge for tomorrow's changing world. 24The experiential approach overcomes this limitation by promoting a view of knowledge not as a given, but as something flexible and responsive to specific needs. In this respect, action learning is closely allied with action research--that is, research which is designed not just to study problems, but simultaneously to be part of the mechanism for developing and implementing the solutions. 3~'32 An example would be to evaluate an immunisation service while continually feeding back the epidemiological and other findings to the key actors, discussing consequent modifications to the service, and evaluating their effects. As with action learning, a feature of action research is that it develops according to specific, changing requirements. It can also bring together the endeavours of theorists and practitioners, which might go a long way towards bridging the academic/service divisions in our discipline. Teachers who switch to experiential methods can expect many more consequences than just closer links with service colleagues and current issues. It is altogether a more democratic and egalitarian philosophy of education in which they become not so much teachers as facilitators; not so much sources of knowledge, as guides to a network of potential sources. Their role is also to provide an environment in which experiential learning becomes possible. Many teachers will be relieved to be able to admit freely that they don't always know the answers, and many will value the stimulation and the release from teaching the same old material on every course. However such a role is demanding; it is no soft option. Nor should one underestimate the change of attitude that would be required: 'It is crucial to establish an appropriate emotional tone for learners: one which is safe and supportive, and which encourages learners to value their own experience and to trust themselves to draw conclusions from it. '33 Such an ethos will not come easily to medical educators brought up on ward rounds and conference presentations! Experiential learning can be subversive; it is apt to breed inquiring, independent-minded people who are ili disposed to accept meekly what teacher tells them. (To use the terms of Transactional Analysis, it develops the adult not the adapted child. ~8) They will tend to carry this participative, anti-authoritarian attitude with them to work and to want to use their skills not merely to establish facts, but to change things? 4 To use a buzz-word, experiential learning is empowering. On the other hand it breeds a healthy scepticism of one's own knowledge and abilities, and a strong respect for the contributions of others. Moreover experiential learning starts from the premise that one needs to scrutinise one's

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performance openly in order to improve, which leads very naturally to a life-time habit of peer review and audit.

The epistemological consequences The subversiveness can go deeper than mere mistrust of received wisdom. The more radical exponents of experiential learning have noted that it stimulates epistemological change by encouraging a variety of conceptual frameworks and enabling ad hoc solutions to multi-paradigmatic and ideologically rooted problems. They even hint at its potential for synthesising the dialectic between the hermeneutic and the empiricist Weltanschauungen, and see it as an heuristic device that will establish the Habermasian praxis of emancipatory critical knowledge 35,36. . . But don't panic! Some o f them do write comprehensible English, and argue simply that people discover new ways of knowing about things and come to question the standards by which they judge the truth of what is known. That would be no bad thing for our discipline, when one considers the deeply political nature of public health, and the consequent dangers of assuming that one's own way of seeing things is the only correct one. There are those of us ('social constructionists') who hold that all knowledge is the product o f the social, political, economic, cultural and historical circumstances in which it is produced. 37 If so, then the culture o f experiential learning would produce a new and distinctly different kind of knowledge base, and research methodology, for public health. Public health research could no longer be held aloof from the grubby question of implementing the findings, since the latter would be a key requirement of the research. 38 For example, we currently devote a great deal of research effort to epidemiological questions. (What are the risk factors for a given disease? What interventions reduce them?) But action learning and action research would require theories which extend to the practicalities of introducing successful interventions. (Why do some fail where others succeed? What factors are likely to help future success?). The current preoccupations of service public health physicians, such as needs assessment, service specification, quality assurance or clinical audit require academics willing to pioneer new methodologies in which the stale debate between epidemiological purists and managerial pragmatists is superseded. Perhaps experiential learning programmes allied to action research might therefore lift us beyond our current eclectic mixture of skills and sciences, to a unique synthesis--a coherent theory of public health practice.

Over the Top? I have made bold claims for experiential learning not surprisingly considering the enthusiastic bias o f the writings on which this essay is based. Before any commitment can be made to 'go experiential', we should examine several critical questions that might be raised.

Effective? Has the new approach to learning been demonstrated to be better than conventional pedagogy? The literature is full o f anecdotal reports of successes. Although the evaluations are not always as rigorous as one would like outcome measures in continuing professional education are no easier than in health care--they compare favourably with the evaluations of many of the major movements that our own discipline has espoused in recent years, such as health promotion or medical audit (which incidentally themselves display a recent shift of philosophy similar to the one I have been describing).

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By contrast most evaluations of the traditional lecture method cast doubt on the extent to which we currently rely on it. 8'~9

Dangerous? Might the action learning approach, because it insists on using real problems to learn from, unleash the untutored learner to do considerable damage in the workplace if the project goes wrong? This has not usually proven to be a problem in the industrial setting, but obviously requires care. The point, though, is that proper prior assessment of the learning needs will naturally also entail full assessment of the learner's capabilities. Thus the allocation of problems for the learner to solve would be if anything more appropriate, and more carefully monitored than at present.

Book burning? Is the experiential learning movement anti-intellectual, in that it plays down the importance of established knowledge (or at least of established academics!)? Such an objection would miss the point of the kind of experiential learning being advocated here, which is that the academic, theoretical contribution to mainstream public health should be increased. Nevertheless it is possible that learning groups could throw the academic baby out with the bath water and end up wallowing in mutual ignorance. The tutor needs to ensure that does not happen.

Trivial research topics? Might pure research for the advancement of knowledge become swamped by short-term problem solving? No, because the relative priorities between pure and applied research would be a matter for academics and their funding bodies to decide, which should ensure that we don't descend into the medical equivalent of 'hamburgerology'. Moreover, as I have suggested, the current distinction between pure and applied theory is not helpful, and a new theoretical framework which combined the two would be likely to be of benefit to the long-term goal, which is to improve the public health. Theoretically sound? Are the theories that underlie experiential learning well grounded in scientific evidence? It would seem so; but Jarvis has commented that the significance of experiential learning 'should not obscure the fact that it attained the status of a theory in a time [the 1960s] when the structures o f society were conducive to it, rather than because it was valid theoretically or adequate as a description of the process of adult learning'. 4° I would not presume to judge the scientific standing o f educational theories, but they would not be alone in being accepted because they fit in with the times rather than because they are objectively proven. Social constructionists have said the same about the whole of Western science,4~,42,43and not least of medical knowledge. 44' 45 Nothing new? 'But surely, aren't we doing it already?' (This objection will be familiar to all of us who have recently been struggling to introduce medical audit amongst our clinical colleagues.) Yes indeed, as with medical audit, experiential learning may have been happening, 39'46 but there's a long way to go yet. Some of the management development programmes attended by the more senior public health physicians follow the precepts of experiential learning. Some Part I courses have service-based project work as a formal part of their programme. Many regions now have learning contracts for trainees (though ours is very watered down from the version promulgated by Knowles, the main architect of this aspect of experiential learningS6). The practical experience gained as a trainee has the potential for experiential learning, but usually lacks the essential element of structured reflection to take the learner around the whole learning cycle (Figure 2) in the company of tutor, boss and peers. The new style Part II examination requires some reflection on how

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real-world projects are carried out, but still falls far short of fully-fledged experiential learning. For example it is constrained to individual rather than team work, so that the peer group component of the tetrad is excluded. And it is confined to three or four projects out of a life-time's work. It is clear from the tone of the Faculty Training Conferences and from initiatives around the country, that many aspects of our training are ready to move towards experiential learning. Indeed there have been increasing initiatives towards such methods a m o n g medical educators more generally. 29"3°'39 But while there might be supporters of the idea, there will also, judging from the experience o f other disciplines, ~4"~5,~6"47be objections rooted in the fear and resistance of staff and students alike, for we would be challenging centuries of tradition. The medical establishment's reluctance to rethink its professional education goes deep; we are steeped in a heritage which we are unable or unwilling to shake off. But then aren't public health physicians supposed to be skilled 'change' agents? I am not for a m o m e n t suggesting foisting experiential learning onto public health medicine in the sweeping way that so m a n y other changes are being foisted upon us. But perhaps the time has come to evaluate experiential learning in public health. We needn't go over the top, but we could reconnoiter.

Pushing the Boat Out We would be setting out across, for us, relatively unfamiliar waters, but they are not uncharted; others have already explored them. There are therefore m a n y techniques we could adapt, most of which are variants on a single t h e m e - - t o structure the process of reflection on one's practical experience in such a way that the essential tetrad of learner, tutor, boss and peer group are all involved. All such methods would allow a natural progression to life-long continuing education based on similar principles. And all of them would allow public health schools considerable scope for establishing multidisciplinary learning groups, and so foster a more co-operative alliance of the m a n y agencies that could help improve the public health. I shall do no more than to suggest three simple examples that could be a starting point. After all, experiential learning must itself be developed through experience, not by an academic writing an article such as this.

Open diary review. keeping a full and honest diary of one's work experiences to be shared with a training group and/or mentors and/or tutors and used continually as the starting point for further academic tutelage. 48"49,5° Learning sets: organising day- or weekly-release courses such that the trainees and their tutor start by analysing the problems they have had with their recent service work. They ask the academic resources of the course organisers for relevant new knowledge or skills to help with those problems, and where possible they work on it together. They then go back into the service to try out the new material they have helped each other acquire. Finally, they come back to reflect together on how that material helped them with their work, so beginning the c y c l e - - o r rather the spiral--again 3~'s~ (Figure 3). Action learning teams--structuring the training in a region so that teams of trainees work as a group with one or more academic tutors/facilitators, working on service projects commissioned by the directors of public health. 23 (Which, incidentally would also help to achieve a critical mass of public health physicians when they are thin on the ground.)

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Figure 3 Stages: 1. service experience; 2. reflect on good and bad experiences; 3. listen to experts/ academics; 4. decide to acquire new ideas or techniques; 5. try new techniques; 6. compare notes on what happened; 7. decide on further theoretical input; 8. further plans for acquiring and trying new knowledge. (With acknowledgements to the Further Education Unit 32)

Medical Education for the Nation's Health? In his article on medical education, A|wyn Smith argues that we need to bring the o u t m o d e d educational philosophy of the profession 'into line with the medical needs of h u m a n societies approaching a new century in which not only the characteristic threats to health but the needs of h u m a n beings in general will be quite different from those of the 19th century in which our existing traditions were established. Health is inescapably a social and political issue rather than a technological one: The education of doctors will have to take account of that. '7 He eschews what he calls the impertinence of offering his own solutions to the problems of the entire medical educational establishment. But it is time to risk a little local impertinence within our own discipline. Public health physicians now have unprecedented opportunities to re-shape their professional training. Alwyn would be grabbing the opportunity had he not been about to retire to a life of sailing. Let us take up the challenge. N o t only will experiential learning make public health a more effective discipline, but we might even set an educational example to help drag the rest of medical education into the 20th century--just in time for the 21st. Bon voyage.

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References 1. Royal Yachting Association. (1987). R YA Handbook on Navigation. David and Charles: Newton Abbot and London. p. 12. 2. Lewis, J. (1986). What Price Community Medicine? Harvester, Wheatsheaf Books: Brighton. 3. Lewis, J. (1986). The changing fortunes of community medicine. Public Health, 100, 3 10. 4. Anonymous, (1985). Griffiths: 'dismay and disillusion' among community physicians, British Medical Journal, 291,843. 5. Acheson, D. (Chair) (1988). Public Health in England." the Report of the Committee of lnquiry into the Future Development of the Public Health Function; Cmnd 289. HMSO: London. 6. Working for patients. (1989). HMSO: London. 7. Smith, A. (1981). Doctor in need of a cure. Times Higher Educational Supplement 3 April. pp. 8-9. 8. Bligh, D. (1972). What's the Use of Lectures? Penguin: Harmondsworth. 9. Knowles, M. S. (1984). The Adult Learner--a Neglected Species, 3rd ed. Gulf: Houston. 10. Donaldson, R. J. & Hall, D. J. (1979). The work of the community physician in England. Community Medicine, 1, 52~58. 11. Harvey, S. & Judge, K. (1988). Community Physicians and Community Medicine. Research paper No 1, Kings Fund Institute. Kings Fund: London. 12. Gabbay, J. & Williams, D. (1989). Community physicians and general managers: experience and expectations. Journal of Management and Medicine, 3, 193-215. 13. Kolb, D. A. (1984). Experiential Learning--Experience as the Source of Learning and Development. Prentice Hall Inc: New Jersey. 14. Boud, D., Keogh, R. & Walker, D. (1985). Reflection: Turning Experience into Learning. Kogan Page Ltd: London. 15. Weil, S. W. & McGiI1, I. (eds) (1989). Making Sense of Experiential Learning. Society for Research into Higher Education and Open University Press: Milton Keynes. 16. Knowles, M. S. (ed.) (1984). Andragogy in Action: Applying Modern Principles of Adult Learning. Jossey-Bass Publishers: San Francisco and London. 17. Knowles, M. S. (1980). The Modern Practice of Adult Education:from Pedagogy to Andragogy. (2nd edition) Follett: Chicago. (Originally published in 1970 as The Modern Practice of Adult Education: Pedagogy versus Andragogy). 18. Harris, T. A. (1967). I'm O K - You're OK. Avon Books: New York. 19. Schon, D. (1983). The Reflective Practitioner. Basic Books: New York. 20. Rogers, C. (1983). Freedom to Learn for the 80s. Charles E. Merril: Columbus. 21. Rogers, C. (1961). On Becoming a Person. Constable: London. 22. Brookfield, S. (1985). A critical definition of adult education. Adult Education Quarterly, 1, 4449. (Quoted in Weil, S. W. & McGill, I. (eds) (1989) Making Sense of Experiential Learning. Society for Research into Higher Education and Open University Press: Milton Keynes. p. 62.) 23. Revans, R. (1983). The ABC of Action Learning. Chartwell-Bratt: Bramley, Kent. 24. Revans, R. (1971). Action Learning in Hospitals. McGraw Hill: Maidenhead. 25. Further Education Unit/Professional, Industrial, and Commercial Updating. (1986). Learning from Experience. FEU: London. 26. Beck, J. & Cox, C. (eds) (1980). Advances in Management Education. John Wiley and Sons: Chichester. 27. Kolb, D. A. (1984). Experiential Learning--Experience as the Source of Learning and Development. Prentice Hall Inc.: New Jersey. pp. 8641. 28. Schon, C. & Argyris, D. A. (1974). Theory in P,actice: Increasing Professional Effectiveness. Jossey-Bass Publishers: San Francisco. 29. Neufeld, V. R. & Barrows, H. S. (1984). Preparing medical students for lifelong learning. In: Knowles, M. S. (ed.) Andragogy in Action." Applying Modern Principles of Adult Learning. JosseyBass Publishers: San Francisco and London. pp. 207-226. 30. University of Southern California. (1984). Self-directed learning for physicians at the University

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