Is there a difference between education and training?

Peter J. Fabri, MD, PhD, FACS
Associate Dean, Graduate Medical Education
University of South Florida College of Medicine
Tampa, FL

It has been 35 years since I graduated from medical school and decades since I finished my last fellowship. I have spent my entire surgical career on full-time medical school faculties, serving as residency program director for 10 years and as associate dean of graduate medical education for the past 14 years. Imagine my own surprise when I stumbled on the sudden realization that the terms education and training are different. Although at times used interchangeably by academic surgeons, the difference is real.

A number of years ago, I was asked to serve as dissertation advisor for a doctoral student in our College of Education who wanted to study “medical informatics.” I agreed, but that meant that I actually had to learn something about formal education. I had the computer part in hand, but I had never actually studied concepts of adult learning, curriculum design, evaluation methods, nor a number of other terms that were foreign to me. I hadn’t even heard of Bloom’s Taxonomy (the fundamental concept of modern education in which competency is attributable to three domains—knowledge, skills, and attitudes—with a hierarchy of acquisition starting at very basic and increasing to very advanced).

A few years ago, I decided to reinvent myself. I enrolled in a graduate program and successfully earned a PhD degree in industrial engineering. Along the way, I selected a course in “training” taught in the Industrial Organizational Psychology program. I really didn’t know what I would learn or even why I was taking it, but it was strongly recommended by one of my colleagues. It turned out to be a great course, and I participated eagerly. Then, BAM! The light went on and I began to understand the differences between what it meant to “train” or be trained compared to “educate” or become educated. The principles of each are related, but ultimately, their aims are different.

Training is concerned with acquiring a skill or the psychomotor domain of learning. This objective can be accomplished through apprenticeships, seminars, workshops, classes, or self-study (eg, reading, observing videotapes, etc.). With training, a task analysis will yield a complete “step-by-step” list of what needs to be done to accomplish the skill being learned. One knows if the training was accomplished when the trainee can reiterate the right answers and/or demonstrate the “approved way” of doing something. Training is specific, has a definite goal and a time, and requires a show of proficiency. In summary, the desired outcome of training is a skill and training has predefined content and is a closed system.

The aim of education is broader than training. It strives to prepare learners to be analytical thinkers and problem solvers by facilitating the learning of principles, concepts, rules, facts, and associated skills and values/attitudes. Its aim is to develop residents’ understanding, abilities to synthesize information, and work skills within and beyond the workplace. Therefore, it often includes what might be considered generic or general topics without a specific, immediate application.

Suddenly, I realized that I had been missing something important all of those years in academic medicine. By lumping everything together in a single “pot,” I was accepting that in-service exams and board exams were measuring something important in surgical training. Well, yes, what they measure is important. But it isn’t measuring the ability of an individual to be a surgeon.

As the course continued, I was scheduled to give a seminar on “transfer of learning.” I had never heard the term before, so I had my work cut out for me. Between textbooks and Google™, I learned that I had been ignorant of another important aspect of the learning process. Transfer means the ability to take an area of learning from one environment (for example, the classroom or the lab) and use it productively in another environment perhaps the operating room or the intensive care unit at a later time. Transfer isn’t automatic. It requires practice, repetition, and feedback. Simply attending a lecture, no matter how well presented, is unlikely to transfer its lesson, even if it is remembered on a multiple choice exam. Imagine. An individual can get the question right on an exam and still get it wrong in the operating room. Almost like left brain-right brain concepts, it is possible for a person to get 100 percent on a test and be a total failure in actual practice. Likewise, I learned the importance of integrating learning transfer into instructional planning by identifying desirable outcomes of the instruction, selecting instructionally appropriate mixes of methods, structuring the content into manageable-sized units of material, and evaluating the learners for transfer and not just immediate retention. This list is not exhaustive by any stretch, but provides a sense of what we can do to promote transfer of learning.

As I learned more, I became enamored of the Dreyfus brothers, both professors of philosophy, who had described the progressive acquisition of competence and the steps required. I heard Hubert Dreyfus talk about how a person learns to drive a car. (While it is necessary to pass a written exam to get a driver’s license, I certainly wouldn’t get into a car with someone who hadn’t been “trained” to drive a car). He spoke about the novice, the advanced beginner, competence, proficiency, and expertise and how an individual passes through identifiable stages on moving along this path. I recalled my terror the first time I was told to make a right turn and how I now can drive 15 miles to work without ever thinking about how to drive the car.

Then I learned about Ericsson’s concept of “10,000 hours.” I was fascinated as I listened to him explain that it takes about 10 years, four hours per day, for a person to become an expert. Chess, dancing, violin. I found myself thinking that must be why surgery is a five-year program. Then I realized that five years of residency isn’t enough. Two years of clinical medicine in school plus five years of residency means that an individual still has a while to go.

Now that I have completed my degree, honestly proud of my accomplishment at age 60, I can look back at all of the myriad things I learned: knowledge, skills, and attitudes. But I also realize that I’m merely “competent,” not “proficient,” and certainly not “expert” as an industrial engineer.

I wish I had known this 35 years ago when I started working with medical students as a surgical resident. I wish I had realized the complexity of what I was doing during my years as surgical residency director. But I’m glad it wasn’t too late. I still have some miles ahead. What advice would I give now to a new assistant professor of surgery? Go to school. Learn about how people learn. Put “see one, do one, teach one” where it belongs—in a museum. And most importantly, learn about the difference between education and training. That young resident might some day be operating on you.

Online April 7, 2008