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Cognitive Flexibility

At higher levels of learning in health care, cognitive flexibility theory may aid complex instructional situations. There are two key principles:

  • First, focus on common beliefs and misconceptions that apply to related concepts, and challenge those misconceptions.

  • Second, de-emphasize compartmentalization of knowledge.

An illustration of the first principle is the misconception that any urethritis is gonococcal and therefore a sexually transmitted disease (STD). Challenge this misconception by making the learner aware of multiple infectious agents that can cause urethritis, and non-infectious causes as well.

An illustration of the second principle is the problem of "linear thinking" to oversimplify complex problems into simple, exclusive, sequential "cause and effect" events. For example, the student has learned that Paget disease of bone leads an increase in the serum alkaline phosphatase, and then links this laboratory test exclusively with that disease, but ignores the more complex relationships of alkaline phosphatase to multiple bone diseases, or to other sources, such as biliary tract, gastrointestinal tract, or placenta.

Concepts and Context

Apply these principles and avoid the problems by practicing the use of knowledge in multiple patient settings in different ways. Concept mapping may help in this regard. It is important to learn the use of information in context, but concepts must be developed that can be generalized to additional contexts.

For example, a student may have learned about bleeding with aspirin ingestion in the context of gastritis, but not recognized that bleeding may have been promoted by the action of aspirin upon platelets.

Educational research for over 30 years has shown that "backward" learning is more effective than "forward" learning:

  • Instead of just memorizing disconnected facts in isolation (forward learning), learn the material from a clinical context (fill in backward from the clinical scenario). Determine how each fact or concept interacts with the others. Build associations and links to other facts and concepts.

  • If you learn about diseases from a clinical context, then you will become good providers of health care, and also have the ability to handle basic science concepts as well and pass your examinations. If you learn isolated facts, you may pass the exams, but will not necessarily be any good to the persons who need quality health care.

Avoid the temptation to "jump to conclusions" after spotting just a fact or two, without considering options or applying a schema to determine how to make use of additional information.

Knowledge Transfer

Knowledge acquired in the context of one disease example may be utilized to diagnose a related, but not similar, disease in another patient context. Shifting the context is difficult, because it requires recognition and application of the underlying concepts.

If just the concept is taught, as in a lecture or in reading text, then novice learners have a transfer rate of 5% to new problems. Illustrating the concept with one good example will increase the rate of transfer to 25%. Practice with multiple examples pushes the transfer rate close to 50%.

Therefore, initial teaching to novice learners can embed concepts into problems. Then, concepts are reinforced with additional examples. When further practice incorporates multiple concepts across a wider spectrum of disease processes (such as multiple disciplines or organ systems, not just one), then knowledge retention and transfer increases.

Experts have the ability to recognize the concepts and apply them with multiple long-term memory schemas in multiple contexts.


Norman G. Teaching basic science to optimize transfer. Med Teach. 2011;31:807-811.

Patel VL, Yoskowitz NA, Arocha JF, Shortliffe EH. Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education. J Biomed Inform. 2009;42(1):176-97.

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