A primer on adult learning theory for ophthalmology education: foundations and narrative review

Introduction

Adult learning theory (ALT) is a framework rooted in the concept of how adults learn (andragogy) versus how children learn (pedagogy). This collection of principles demonstrates the unique needs of adult learners and proves useful when applied to the design of effective learning environments for adults. It provides a foundation for developing learner-centered strategies and enhancing program efficacy. Hence, graduate medical education programs have increasingly recognized the value of incorporating ALT within residency training to fulfill the unique needs of adult medical trainees (1). Implementation to improve graduate medical education by the Accreditation Council for Graduate Medical Education (ACGME) has been trialed in the past, with goals to improve resident patient care, medical knowledge, professionalism, interpersonal skills, practice-based learning and improvement, and systems-based practice, with certain programs proposing long-term projects to identify and implement solutions towards this goal (2).

Current guidelines in ophthalmology residency encompass comprehensive clinical and surgical experience with adequate instruction in all subspecialties within ophthalmology (3). Importantly, ophthalmology trainees desire to engage in programs that emphasize surgical training (4-7). Additionally, traditional curricula often focus on knowledge and didactic education and less on experiential learning (8). In a field in which demonstration of both scientific knowledge and surgical skills is required, coupled with evolving technology and novel medical discoveries, ophthalmology educators and learners can benefit from understanding the principles of ALT to better tailor educational efforts to meet the needs of adult learners in training. The last review on the implementation of ALT into ophthalmology training was done in 2011 by Roberts et al. (9), who effectively outlined ALT principles and provided suggestions for training programs.

The traditional Halstedian model of “see one, do one, teach one” in the apprenticeship model of education (10) faces significant pressure and modern constraints (e.g., resident work-hour regulations, heightened patient safety imperatives, the increasing complexity of microsurgical techniques, and the economic pressures of clinical service).

In this article, we identify specific, evidence-based educational deficiencies and offer ALT as a potential solution and provide background information to the reader on the problem. We describe ALT and how it can be used to address specific inefficiencies in contemporary ophthalmology education and why ALT is uniquely positioned as a potential countermeasure.

We perform a narrative review of the current methods of ALT and how they have been implemented in ophthalmology training programs and provide suggestions based on challenges described by ophthalmology learners. We present this article in accordance with the Narrative Review reporting checklist (available at https://aes.amegroups.com/article/view/10.21037/aes-25-37/rc).

Methods

The objective of this article was to conduct a review of the challenges in ophthalmology education, ways that ALT has been implemented, and the efficacy of these interventions. A search of literature was performed across two electronic databases: PubMed and Scopus. The search included keywords of “ophthalmology” AND (“adult learning theory” OR “self-directed learning” OR “experiential learning”). The search included studies published within the last 10 years from 2015 to 2025. The latest search was conducted on 15 November 2025. The inclusion criteria comprised original studies, reviews, and peer-reviewed articles in English relevant to ALT principles and involving ophthalmology trainees, educators, or teaching methods. Exclusions were made for notes, correspondences, comments, editorials, studies unrelated to ophthalmology education or ALT principles, and non-English publications. Study screening involved two independent authors (S.Y.C. and S.N.) using systematic review tool Covidence. Any conflicts were resolved through discussions until a consensus was reached (Table 1).

Core concepts of ALT

The concept of andragogy was solidified by Malcolm Knowles in the 1980s, who indicated that adults learn differently from children using six core assumptions (11), with the six core values that differ between the two outlined in Table 2.

Adults have an increased need for intrinsic inquiry and motivation, whereas children and adolescents are more motivated by extrinsic drivers and the environment. Understanding these differences in the needs of adults compared to their younger counterparts is crucial in building an effective educational framework geared to these learners.

ALT frameworks

ALT encompasses a wide range of concepts that can be categorized into instrumental, humanistic, transformative, social, motivational, and reflective theories (11).

• Instrumental theories include behaviorism, cognitivism, and experiential learning, which focus on the individual experience. Behaviorism describes the ways in which environmental stimuli shape one’s behavior, and cognitivism emphasizes how learners process and structure information. Experiential learning, developed by David Kolb in 1984, highlights participation through structured experiences organized by educators. In this cycle, the learner has a concrete experience that leads to observations and reflections, which then develop abstract concepts and generalizations. This allows the learner to test their implications in various situations (11).
  Experiential learning by Kolb
  • Concrete experience: doing or having an experience;
  • Reflective observation: reflecting on and reviewing the experience;
  • Abstract conceptualization: taking the lesson into action;
  • Active experimentation: drawing conclusions from the experience.
• Humanistic and self-directed learning (SDL) theories emphasize learner-centered environments to promote self-efficacy and intrinsic motivation. Heavily based on Knowles’ concept of andragogy, it empowers learners to take the lead on their own education.
• Transformative learning theory emphasizes reflection that allows learners to reassess and challenge their assumptions that stem from previous personal or professional experiences.
• The social theories of learning and cognition, often referred to as ’situativity’, describe that learning is shaped by various inputs from social communities, culture, and the environment (12). Reasoning and knowledge are influenced by interactions and factors outside of one’s immediate knowledge. It assumes that learning and thinking are social activities, structured by available tools, and influenced by their setting.
• Motivational models, including the self-determination theory, emphasize the learners’ need for self-regulation, motivation, and active engagement (13).
• Reflective models assume the importance of reflection as it leads to action and change.

With effective integration of ALT principles, educators and learners can expect improved knowledge retention, increased motivation, greater clinical competency and confidence, and a cultural shift in education (1,2). Learners will be able to extract and retain more material with the combination of active participation and experiential learning. Through these practices, learners will build confidence in clinical knowledge and procedural ability. The shift to self-directed, autonomous learning will enhance their intrinsic motivation for further education and improve outcomes of both learners and educators.

ALT in ophthalmology education

The importance of ALT has become increasingly prevalent in healthcare education to enhance student engagement, curriculum efficacy, and skill development. With demands for clinical competency, surgical skills, and continual learning, ophthalmology education continues to explore innovative methods to increase teaching efficacy (4-7). Recent studies have evaluated the efficacy of ALT implementation in ophthalmology training, including SDL, problem-based learning (PBL), simulation-based learning (SBL), experiential learning, and effective feedback.

SDL and PBL

A study by Atta and Alghamdi (14) investigated the efficacy of SDL versus PBL in 60 medical students enrolled in an ophthalmology course in Albaha School of Medicine in Saudi Arabia. SDL included two case histories with learning objectives, which were discussed with a tutor after individual investigation. PBL included groups of twelve students with two case-based scenarios under the supervision of a tutor. The students underwent four sessions, with each session covering different learning objectives such as case management, differential diagnosis, findings, and summary. Students were given a final examination of 15 questions for SDLs and 15 questions for PBLs. These findings were compared to the students’ scores in the otolaryngology course. They found significant differences between SDL and PBL scores within the ophthalmology course, with PBL resulting in a 13.3% increase in high scorers. Otolaryngology scores, however, showed no statistically significant differences between the scores of SDL and PBL examinations. These differences suggest the unique challenges of ophthalmology education compared to other clinical topics that may benefit from PBL or case-based learning (CBL), which facilitates group-wide discussion and inquiry compared to SDL. Although both CBL and SDL utilize ALT principles, one method may better suit the needs of certain trainees, and individual needs should be assessed prior to implementation.

Another study by Khan et al. (15) investigated the perception of CBL in clinical subjects, including ophthalmology. A total of fifty students from Al-Tibri Medical College in Pakistan who completed clinical postings in otolaryngology, ophthalmology, and obstetrics and gynecology were given self-designed questionnaires to assess the perceived effectiveness of CBL. Students across all three specialties agreed that CBL is an effective learning method that helps solve questions, boost communication skills, and develop independent learning abilities.

A study by Sahoo (16) evaluated the effectiveness of SDL in ophthalmology clinical training for both learners and instructors. Fifty-one students undergoing ophthalmology training were asked to complete a questionnaire regarding utilization and satisfaction with the SDL slots placed in their schedules. The majority of students either agreed or strongly agreed that SDL stimulated independent learning and improved critical thinking. Two students stated that resources were insufficient for independent learning. Most students perceived three hours to be sufficient for independent learning and felt that the weekly assessment of SDL topics was helpful in utilizing SDL hours.

Similar findings were described in the study by Zafar (17), which investigated academic performance after SDL versus traditional teaching at the Armed Forces Institute of Ophthalmology in Pakistan. During the week, 25 students underwent traditional lectures and demonstrations while 25 students engaged in SDL with access to teachers for guidance, if desired. Both groups completed a pre-test and post-test assessment of 25 multiple-choice questions before and after the week. The SDL group showed higher post-test scores than the traditional learning group.

Jun Rong et al. (18) evaluated the use of a surgical instructional video as a tool for SDL in learning surgical skills. First-year ophthalmology residents who have completed supervised wet lab training and a microsurgical course were assigned to watch a 10-min instructional video on phacoemulsification as a group. They felt that the video highlighted insights normally not emphasized in live surgery, and subtitles with key points helped emphasize key messages. However, they felt that it could not replace live surgery or the microsurgical course in hands-on training and feedback. Utilization of the video for SDL was found to be beneficial for knowledge reinforcement, establishing a baseline understanding of the surgery, and reducing stress on educators who must often estimate the residents’ knowledge about the procedure during training.

Experiential learning and SBL

Feng et al. (6) evaluated 25 ophthalmology trainees’ perceptions of their gonioscopy learning experience using an electronic survey that included their confidence in the procedure, satisfaction with training formats, and potential barriers to their training. They discovered that over a quarter of trainees were dissatisfied with the quantity of training and the lack of clinical time. The perceived satisfaction levels of teaching methods were highest in consultant teaching and SDL. Trainees’ desired method to improve their training was favorable towards ‘direct feedback in clinic using patient images’, ‘online materials’, ‘small groups’, and ‘simulation’.

The study by Alkharashi (4) investigated the effectiveness of experiential learning in cataract surgery. Thirty-two students were divided into a control group, which attended a lecture, and an experiential group, which attended a wet lab session. Both groups were given a pre-lecture quiz and a post-lecture quiz. Both control and experiential groups demonstrated an increase in knowledge between pre- and post-quizzes. However, students in the experiential group showed a 5-point increase compared to a 2.5-point increase in the control group.

Tajran et al. (19) investigated the efficacy of virtual reality-based SBL in second-year ophthalmology residents. Fourteen residents engaged in a 4-h lab using Oculus virtual reality headsets and zSpace stereoscopic displays that included glaucoma and retina procedures and examinations. The pre- and post-session surveys, knowledge assessments, and anatomical drawings demonstrated a significant improvement in understanding anatomy, such as the iridocorneal angle, aqueous flow, and pathology.

Kwok et al. (7) investigated the efficacy of implementing an online peer fundus photograph matching exercise versus students who did not participate on the students’ ability to perform direct ophthalmoscopy. They found that students in the experimental group had increased confidence levels and increased speed in performing ophthalmoscopy, suggesting that the self-directed simulation learning increased both skill and confidence of trainees.

Feedback

Ahmad et al. (20) discussed multisource feedback and its receptiveness among house surgeons in the Institute of Ophthalmology at Mayo Hospital, Lahore. When conducted effectively, multisource feedback allows for reflection and improvement in performance. Two focus groups of 6 surgeons each were held. They found that multisource feedback yielded mostly positive reactions and positive learning behavior through which participants sought to improve themselves. However, a minority had a negative change, while one did not show any change to the feedback received. Barriers mentioned included participants feeling that they already ‘tried their hardest’, a unilateral chain of feedback from seniors to juniors, a lack of a clear outline provided prior to the session, and the unfamiliarity of participants with their raters. It was emphasized that feedback would be better accepted if such barriers were addressed.

Limitations

As SBL is recognized and efforts to implement such learning methods are made, one barrier that programs face is the lack of facilitators and faculty who share the same philosophy and training to support these efforts. The article by Labuschagne et al. (21) emphasized the need for faculty development to sustain simulation-based training in ophthalmology. They proposed an ophthalmology faculty program design including problem identification, targeted needs assessments, goals and objectives, educational strategies, implementation, and evaluation and feedback. Although faculty who incorporate SBL are likely to create an effective learning environment, they face challenges such as institutional mission and philosophy, different training levels, and different understandings of ALT principles. Institutional mission and education must be aligned for effective and efficient skills training for all involved parties. They suggest that SBL, with the use of novel technologies such as virtual reality models, animal models, and other trainers, can rapidly increase surgical competence and enhance patient outcomes. To address the various levels of simulation knowledge, faculty knowledge levels should be established prior to starting development to address individual needs and capabilities of SBL implementation. Additionally, faculty should set goals that align with their specific program to predict future needs. Educator training needs can be addressed through short didactic presentations, interactive training to plan simulations, and hands-on practice to provide feedback in SBL design.

Filipe et al. (22) discussed similar challenges in faculty development in surgical education. However, they propose the use of international collaboration and online learning to enhance curriculum design and SBL. This study included 10 Congolese ophthalmologists who participated in a monthly webinar program on curriculum design to incorporate ALT principles such as PBL, flipped classrooms, and reflection. Participants expressed enjoyment in the program and dedication to advancing teaching. Utilizing online resources can assist remote faculty development, especially those who live in under-resourced areas.

We acknowledge the limitations on the efficiency of education in SBL and PBL, including the substantial faculty workload, the potential for student resistance associated with flipped classrooms, and the potential for lack of generalizability or sustainability of these training options into real-world surgical performance. In addition, the lack of structured debriefing, poor curriculum integration, and the potential for a significant “fidelity gap” between the simulator and the live operating environment are significant potential barriers.

Baxter et al. (23) emphasized a critical element of the combination of simulation with intensive surgical and wet lab training, and thus the success of the program may not be attributable to the technology alone but to the entire educational ecosystem in which it is embedded. We wish to emphasize the complexity of this ecosystem and urge program directors to avoid a superficial approach that might lead to an overly simplistic, naïve, or ineffective implementation by educators.

Current literature also demonstrates that barriers to ALT implementation include challenges in faculty development, institutional philosophies, and resource allocation (19,20). Establishing institutional priorities and cost-benefit analysis requires individual assessments of these changes; however, both low- and high-cost models as discussed in the above literature can be implemented to achieve learning outcomes outlined by the program. Ideal methods of education may differ based on faculty knowledge and experience with certain programs, availability of facilitators, and learners’ training levels. Organizations, faculty, and programs will need to dedicate time to allocate financial resources, time, and manpower to optimize shifts in their educational methods.

Discussion

Educators have increasingly been adapting ALT principles into medical education and ophthalmology curricula to increase relevance and active learning (13). Existing literature demonstrates successful efforts integrating ALT principles such as SDL, PBL, SBL, experiential learning, and effective feedback into ophthalmology training and education. All studies have found positive results of ALT compared to traditional learning methods such as lectures and faculty demonstrations.

The existing literature on the application of ALT in ophthalmology education primarily comprises original articles and cross-sectional studies. The majority of articles discuss the application of SDL, PBL, and SBL, reflecting the widespread awareness of such ALT derivatives in ophthalmology training efforts. While cross-sectional studies provide valuable insights into trainee perception and short-term outcomes of these implementations, they lack long-term outcomes and changes in trainee performance. Furthermore, a recurrent issue across most studies is the use of small sample sizes, which hinders the external validity of the findings. Additionally, many of these studies were performed outside of the United States, where medical education is widely variable in training length and curriculum design. There is no consensus on one best method to implement ALT, as many studies highlight various aspects of ALT principles with different approaches to each.

To establish a stronger argument for the incorporation of ALT into ophthalmology education, future studies must include a larger sample size over a longer duration of time, including surveys from learners as they advance in their training years and feedback from educators on their perceived impact of teaching methods. Such outcomes can provide both institutions and individual faculty with reliable suggestions to make curriculum changes and address the barriers that need to be overcome.

Conclusions

Integrating ALT into ophthalmology education offers a robust, evidence-based framework to enhance effectiveness and improve outcomes for both learners, instructors, and future patients. By embracing these principles that promote experiential learning, SDL, reflection, and feedback, ophthalmology educators and mentors can better address the evolving needs of today’s adult learners. Ophthalmology continues to evolve in its scientific advancement, surgical refinement, and integration of novel technology. ALT principles provide ophthalmology trainees and educators with a systematic structural framework to face new challenges and remain adaptable to this ever-evolving field.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Andrew G. Lee) for the series “Special Consideration for Teaching and Learning in Neuro-Ophthalmology” published in Annals of Eye Science. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aes.amegroups.com/article/view/10.21037/aes-25-37/rc

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-25-37/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-25-37/coif). The series “Special Consideration for Teaching and Learning in Neuro-Ophthalmology” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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