Implementing Kolb´s Experiential Learning Cycle Journal of Medical Education and

Curricular Development
by Linking Real Experience, Case-Based Discussion Volume 9: 1–5
© The Author(s) 2022
and Simulation Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/23821205221091511
M. Wijnen-Meijer1, T. Brandhuber2, A. Schneider2 and P.O. Berberat1
1TechnicalUniversity of Munich, School of Medicine, TUM Medical Education Center, Munich, Germany.
2TechnicalUniversity of Munich, School of Medicine, Institute of General Practice and Health Services
Research, Munich, Germany.

ABSTRACT

BACKGROUND: Background: To prepare medical students for their future, they must become acquainted with clinical practice, for example by
means of simulations, clerkships and discussing patient cases. By connecting these different approaches, according to Kolb´s experiential learn-
ing cycle, the learning effect can be strengthened.

METHODOLOGY: In the development of a didactical program for students who are being prepared for their role as general practitioners, we have
adopted a new didactic approach, in which educational formats are interlinked, according to Kolb´s experiential learning cycle. The content of
these courses is determined by the Entrustable Professional Activities (EPAs) for the clerkship in family medicine, combined with the most com-
mon chief complaints of patients in the GP’s practice. In 2019, the first course was implemented at the Technical University of Munich, Germany,
with 6 medical students. A first seminar discusses patients who the students have seen for themselves during their clerkship in family medicine. In
addition, matching theory is discussed and skills are practiced. In the next seminar, students apply the acquired knowledge and skills in scen-
arios with standardized patients. Students evaluated the courses as positive. The evaluations show they find discussing personally experienced
patient cases and the opportunity to practice very valuable.

CONCLUSIONS: A course design according to Kolb’s Experiential learning cycle, which integrates experience, theory and simulation, is a valu-
able addition to existing forms of teaching in medical education. Students appreciated both discussing personally experienced patient cases and
the opportunity to re-practice similar cases in a simulated environment. To gain more insight into the learning effects, it is recommended to further
explore this approach in a different context.

KEYWORDS: kolb, simulation, clinical practice, curriculum development

TYPE: Methodology

CORRESPONDING AUTHOR: Marjo Wijnen-Meijer, Technical University of Munich, School of

Medicine, TUM Medical Education Center, Ismaninger Straße 22, 81675 München, Raum 03/
3.14 (3. OG).
Email: [email protected]

1. Background and acquire clinical skills without putting patients at risk.6

In order to prepare medical students for their future work, Moreover, a simulation-based training in handling critically
several didactic settings are used to integrate clinical practice ill patients was shown to improve not only diagnostic and
into medical school. Besides direct clinical exposure discussing medical expertise skills but also non-technical skills, such as
patient cases in seminars, which enable students to learn clinical situation awareness, decision-making, communication, team-
reasoning and simulation-based training, where students can work and leadership.7 Finally, there are various forms of educa-
practice skills such as communication and physical examination tion in clinical practice, ranging from one-day observations to
are frequently used methods.1–3 Courses encouraging clinical carrying out medical tasks under supervision during longer
reasoning, decision-making and problem-solving are of great clerkships.8,9
importance for medical students to apply their knowledge Furthermore, in order to strengthen the link with and prep-
expanding beyond the medical facts.4 For example, the clinical aration for clinical practice, the concept of Entrustable
reasoning mapping exercise (CResME) discussed by Torre et al Professional Activities (EPAs) is increasingly used in the clin-
in 2019 uses clinical information for multiple disease entities as ical phase of medical school and residency.10–13 EPAs are
nodes in different domains (history, physical exam, imaging, defined as essential elements of a physician’s daily work that
laboratory results, etc) and allows students to connect these can be assigned to a trainee once sufficient competences have
nodes of information developing accurate differential diagnoses been acquired. As the amount of supervision is gradually
and/or management plans.5 Simulation tools in medical educa- reduced, students are given increasing responsibility for per-
tion such as simulated patients or task trainers, provide the stu- forming medical tasks.10,11 As a result, students and residents
dents with experiences of patients in controlled setting and grow incrementally in their (future) roles, facilitating the tran-
allow students to experiment, make mistakes, get feedback sition to the next phase. Although the EPA concept was

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2 Journal of Medical Education and Curricular Development

originally developed for residency, it has been implemented in We made the connection between these didactic approaches
medical schools as well.10–12 An important prerequisite for in a program for students who are preparing for their future role
the successful implementation of this method is that trainees as general practitioners. In addition to the regular medical
are regularly observed performing the tasks, so that the school program, these students receive additional courses on
amount of required supervision can be estimated. In addition, topics that are especially relevant to general practice.16 The
it is necessary for the development of the trainee that he/she content of these courses is determined on the basis of EPAs
receives targeted feedback on a regular basis.11,13 for the final yeaŕs clerkship in family medicine, combined
Although all three, the discussion of patient cases, simula- with the most common chief complaints of patients in the
tion and learning in clinical practice are part of most medical GP’s practice. After the cognitive case-based confrontation
curricula, they are usually not directly didactically linked in with personally experienced cases, they faced matching simu-
one single course. There are various chief complaints in lated cases and finally focused und reflected on follow-up
family medicine, which differ greatly. It is different whether experiences of the same cases in general practice reality.
one treats abdominal pain or a common cold. The students This article discusses the methodology and the first experi-
cannot simply extrapolate from cause A to cause ences with this didactic approach.
B. Moreover, there is no standardised training for these
clearly defined chief complaints. 2. Course Design
This lack of integration makes it more difficult for the stu- 2.1. Context
dents to connect the knowledge and skills they have learned
From 2019 a special track has been developed at the medical
in a coherent way. 14 This program aims to create a standard-
isation of training in relation to the chief complaints. school of the Technical University of Munich, in addition to
Combining and integrating explicitly all these three didactic the regular curriculum, to prepare students to work as general
practitioners in rural areas of Bavaria. All students of the clinical
settings can be seen as an implementation of Kolb’s learning
cycle which postulates that effective learning is ideally achieved phase of medical school can apply. The participating students
by progressing through a cycle of four stages (see Figure 1): receive a stipend and mentoring by experienced GPs.
having an experience (“concrete experience”), reflecting on the Participation in the additional educational program is compul-
experience (“reflective observation”), learning from the experience sory. In this context, this course, based on Kolb´s experiential
(“abstract conceptualization” and trying out what you have learning cycle was introduced.
learned (“active experimentation”).16 Additionally the EPA
concept may build a coherent guiding base through the cycle 2.2. Course
and emphasizes the targeted final competence. Selected chief complaints (based on a high frequency and rele-
In Kolb’s learning theory, which fits the constructivist vance in general practice) were linked to specific EPAs (for
approach, the learned knowledge is mentally anchored by a con- example the chief complaint "acute abdominal pain" for the
crete experience, corresponding to this knowledge. This means EPA “Consultation with a patient with acute symptoms”)
that the different didactic methods must be logically linked to and consists of the following components:
each other on the same subject. 15
1. During a clerkship in family medicine, two students are
given the assignment to select a patient that fits the
selected chief complaint. They describe the symptoms
of this patient, anamnesis, physical examination, add-
itional examinations, differential diagnosis, treatment
and further course (Kolb’s “concrete experience” & “reflect-
ive observation”).15
2. During a following seminar (3 hours) with a focus on
clinical reasoning, these students present these patient
cases and discuss them with other students and teachers
(who are experienced GPs). Furthermore, a short knowl-
edge test on the subject, an in-depth input by the tea-
chers and repetition of relevant skills, for example, the
anamnesis and physical examination in case of acute
abdominal pain, is included in this seminar. Therefore
the students elaborate the experienced cases and gain
Figure 1. Adapted kolb´s experiential learning cycle. further specific and structured knowledge and skills
(Kolb’s “abstract conceptualization”). 15
Wijnen-Meijer et al. 3

3. Consequently in a simulation training session (3 hours) Consequently, all students have learned about all 10 chief
the students practice anamnesis and physical examin- complaints.
ation with standardized patients. The cases fit the
same chief complaint, but the students do not know
the details beforehand. The other students and the tea- 2.3. Evaluation
chers watch the consultation on a video screen in a dif- The students were asked to rate the seminars as a whole with a
ferent room and give feedback afterwards. During the score
feedback session, certain parts of the video recordings In order to evaluate the usefulness of this didactic method,
can be viewed and, if desired, the respective students the students who took part in the first two series of the
can view the entire video recording later themselves. course completed an evaluation form consisting of quantitative
By means of this simulation session, the students can questions, supplemented with the questions for qualitative
immediately transfer the newly gained insights to a prac- explanations. The six students (4 female) were asked to rate
tice situation and this in a highly structured and pro- the seminars as a whole using a score from 1 ( = very good) to
tected learning environment (Kolb’s “active 6 ( = very bad). The average grade for the first seminar (discus-
experimentation”).15 sion of patient cases, content presentation and training skills)
4. Finally, the students reflect in the upcoming clerkships was 1.4 and for the simulation training (anamnesis and physical
on the renewed experience with similar cases in a examination with standardized patients, followed by feedback)
portfolio-based matter. Thus, the cycle closes on a 1.6. This shows that the students appreciated the overall design
higher level as it started in the clinical reality (Kolb’s “con- of the course. This is also shown by the scores on the different
crete experience” & “reflective observation”). 15 items, which the students have rated with “ + +”, “ + ”, “ + /-“,
“-“ or “- -“ (see Tables 1 and 2 and Supplemental material).
Most students found the seminars to be instructive, appropriate
to their prior knowledge and coherent. All students also indi-
During the whole course (consisting of 6 hours of seminars, cate that the learning goals are (very) well achieved with this
combined with at least four weeks of education in clinical prac- course.
tice) the specific EPA is the guiding concept that helps teachers All students substantiated their scores with short explana-
and students align during all the different didactic settings to tions. The comments on the first seminars show that the stu-
the aimed at final competency. dents found the level appropriate, also because of the
A total of 10 such courses have been developed, based on the combination of "basics" and more profound knowledge.
10 chief complaints. In each course, 2–3 students prepared the
cases for the first seminar and did the simulations in the second
Table 2. Evaluation results in % of the simulation training (anamnesis
seminar. The other students actively participated in the discus-
and physical examination with standardized patients) - average
sion, observed the simulations and provided feedback. evaluation scores of two sessions (N = 6 for both sessions).

N=6 ++ + + /- - -- N.A.
Table 1. Evaluation results in % of the seminar (discussion of patient
cases, content presentation and training skills) -average evaluation The information on the 50 25 17 8
scores of two sessions (N = 6 for both sessions). seminar was clear and
concise.
N=6 ++ + + /- - -- N.A.
I found the seminar 50 25 17 8
The information on the seminar 58 42 instructive.
was clear and concise.
I found the self-study 50 8 42
I found the seminar instructive. 58 42 assignments instructive.

I found the self-study 50 50 I feel that I have achieved the 42 50 8

assignments instructive. learning goals.

I feel that I have achieved the 92 8 I found the coherence 50 25 25

learning goals. between the parts of this
seminar good.
I found the coherence between 75 17 8
the parts of this seminar good. The contents of the seminar 75 8 17
corresponded to my previous
The contents of the seminar 83 17 knowledge.
corresponded to my previous
knowledge. I found the guidance from the 75 25
teachers stimulating.
I found the guidance from the 100
teachers stimulating. Note: + + = very good; + = good; + /- = satisfactory; - = sufficient; -- = insufficient;
N.A. = not applicable.
4 Journal of Medical Education and Curricular Development

Discussing real-life patient cases was seen as a good way to In other fields, such as engineering and laboratory education,
introduce the frequent chief complaints and made the clinical the didactic approach, according to Kolb, has been applied
relevance clear. Finally, repeating the skills was considered before. Studies in those areas show that the students are more
very valuable. positive and learn more when compared to a combination of
For the simulation training session, the opportunity to prac- teaching methods that are less interrelated. In addition, the stu-
tice with standardized patients, the extensive debriefing and the dents were able to recall the knowledge learned over a longer
honest feedback from other students and teachers were espe- period of time.18,19 Our experience shows that the method is
cially appreciated. The combination with the first seminar, also suitable for less technical studies, such as medicine.
where the required knowledge and skills were addressed, was Our evaluations show that students find discussing person-
also well appreciated. The students who were more advanced ally experienced patient cases and the opportunity to practice
in their studies found the simulated cases a little too easy. very valuable. The evaluations also make clear that the inter-
Opinions were divided about the video recordings: some action with and feedback from the teachers is experienced as
found it unpleasant, others liked the fact that they could very useful. This is in line with the literature on simulations:
re-watch the consultation with the patient. both good guidance by teachers and getting feedback are
important for the learning effect.3 This is consistent with the
results of a comprehensive meta-analysis by Hattie (2008)
3. Discussion into what factors produce a learning effect. He found that
By combining and coherently integrating different learning both teachers and getting good feedback have a major impact
methods, such as clinical experience, case-based discussions on student learning.20
and simulation, continually based on the EPA framework, The special context in which these courses took place, with a
the learning effect can be enhanced. The design of the course small group of students and teachers, who know each other
program described in this article fits well with Kolb´s well, probably plays a positive role and may be the main limita-
Experiential Learning Cycle (see Figure 1) that is widely tion of this evaluation concerning intended transfer to other
accepted as an effective model for learning.15 This model is curricula. It is therefore recommended to implement and evalu-
based on the assumption that there are four phases in a learning ate such a course in another context, with more students and
process, which students ideally all go through. The first phase is teachers involved. An important next step would be a larger
the phase of concrete experience. In our course, these are the real study with more participants, comparing the learning outcomes
patients, who the students encounter in practice. The second with the students who do not take part in this training. The par-
phase concerns the phase of reflective observation, which ticipating students themselves indicate that they were able to
happens when the students describe the patient cases in prepar- achieve the learning goals with this training method, but it is
ation for the seminar. In the third phase, abstract conceptualiza- recommended that this be investigated objectively in a
tion takes place. This is done in the first seminar where the follow-up study. Because the didactic formats and therefore
patient cases are discussed and theory is presented by the tea- the materials needed, such as rooms and equipment for simula-
chers, matching the chief complaint and a specific EPA. The tions, this approach can be implemented well more broadly. In
fourth phase is the phase of active experimentation, in which stu- addition, the workload per student would be reduced with a
dents apply what they have learned in an exercise situation. This rollout for more students.
takes place during the simulation session, in which students There are a number of open questions that deserve attention
practice the anamnesis and physical examination with standar- in follow-up research. First, the direct link between theory,
dized patients, which represent similar cases, as experienced simulation and practice, probably stimulates the transfer of
before in reality, and get feedback on it from teachers, other stu- the learned knowledge and skills.21 It would be very useful to
dents and standardized patients. Finally, the students take these examine what students do better next time they see similar
experiences with them when they meet similar patients in the patients, in practice or in a simulated environment.
next clinical situation (concrete experience) and the Kolb´s The second question concerns the connection with the
Experiential Learning Cycle restarts on a higher level.15 EPAs. These EPAs have been developed for the final year of
The method described also aligns with the ALACT model, medical school. Through these seminars, students already
developed by Korthagen et al in 2001,17 for cyclic professional encounter these EPAs earlier and get feedback on them. It
development, focused on stimulating reflection. The acronym would be interesting to explore whether these students need
refers to the five phases in this model, which are: Action, less supervision to perform these activities during their final
Looking back on action, Awareness of essential aspects, year, or whether the amount of supervision can be reduced
Creating alternative methods of action and Trial. In particular, more quickly.
the phases “looking back on action” and “Awareness of essen- Finally, it will be interesting to investigate whether students
tial aspects” (in our case, describing patient cases and discussing who complete such courses also reflect more actively on their
them in the seminar) would stimulate reflection. actions afterwards, as the ALACT model suggests.17
Wijnen-Meijer et al. 5

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