Facilitating Lifelong Learning

MAJ John Heflin, MC, USA

Faculty Development Fellowship

Madigan Army Medical Center

 

Goals

            To foster a lifelong discipline to self identify deficiencies and engage in learning to improve medical practice skills and patient outcomes

Learning attitudes and preferences

            1. Iowa study compared family practice physicians who attended a refresher course to random sample of family practice physicians who did not attend (37% response rate)[1]

- Preference for concrete settings was greater among those who attended and preference for abstract settings was greater among those who did not attend the course (p < .05)

                        - Active learners preferred to use audio tapes in continuing their education (p =.002) in comparison to reflective learners

- Abstract active learners (convergers) most prefer colleague group activities and Concrete active learners (accomodators) least prefer this method

o        Physicians 55 years of age and older preferred textbooks as a CME method when compared to the younger colleagues (p < .0003)

 

            2. Survey of British General Practioners using the Self-Directed Learning Readiness Scale at the start of their training (n = 216)[15]

                                    - Enjoyment and enthusiasm for learning

                                                Intention to continue learning over a lifetime and using learning to enhance personal growth

                                    - Positive self concept as a learner

Independence as a learner and satisfaction with problem-solving and reading skills, willing to consider difficult study in areas of interest

                                    - Learning doesn't make a difference

                                                Passive receivers of information with low interest in learning, prefer the syllabus with clear instructions and deadlines

                                    - Enjoyment of verbal discussion

                                                Willingness to accept and learn from criticism

                                    - New ideas are related to existing knowledge

                                                Knowledge integrated to achieve personal meaning

            3. Survey of CME activities in Temple University Graduates 10, 15, 20, 25 years after graduation (n= 506 with response rate of 37%)[13]        

- The amount of money spent on textbooks, journals, CME audio tapes, and CME courses in the past year was significantly related to their application MCAT scores (p < .01)

                        - The higher the MCAT sore, the less money spent on CME activities

- The higher the score in undergraduate science courses, the less likely to spend money on CME activities (p < .04) while low scorers spent significantly more money (p < .01)

- The higher the score in undergraduate science courses, the less CME was believed to modify provider medical practice (p < .02)

- The more awards received in undergraduate studies, the more CME was believed to alter provider medical practice (p < .004)

- Individuals in group practices were significantly more likely to obtain CME than those in solo practice (p < .02)

- Graduated in 1953, 1958, 1963 and 1968 so may not be relevant now (those 4 groups were very similar)

            4. Survey of continuing education in Canadian nurses at one hospital (55% return for n = 373)[14]

                        - Nurses spent twice as much time in self-directed activities as in formal education activities

                        - Degree prepared head nurses had greater interest in continuing education than diploma prepared ones

- Nurses on 8 hour shifts attended twice as much continuing education (2x as much formal activity and 1½x as much self directed activity) compared to nurses on 12 hour shifts

Comment: A preferred method of instruction may lead to greater satisfaction but not necessarily result in the most effective learning or improved patient care.

                        - Studies required to measure the outcomes of various instructional methods used on physicians and nurses

 Learning Theories:

            1. Bloom' theory - when favorable conditions for learning are present, students become very similar in ability to learn, rate of learning, and motivation for additional learning.[2]

             Cognitive entry characteristics - presence or absence of prerequisite learnings

             Affective entry characteristics - extent of learner motivation

             Quality of instruction - appropriateness of instruction to the learner

                        Almost all learners can achieve the objective equally well

                        Appropriate classroom procedure is group instruction supplemented by frequent feedback

                        Learners receive help from each other, family, and others (cooperative not competitive)

Should not classify learners as good vs. bad or fast vs. slow as all learners have difficulties

Sufficient time and help should be available for the learners

                        Key to success is the ability to motivate and correct learning difficulties

            2. Problem Based Learning (PBL) - Emphasis on self-directed learning and small-group tutorials to promote lifelong learning through the integration of education with clinical problem solving

                        - Being incorporated into some medical school curricula and may be limited to the two preclinical years or may occur in all four years.

                        - Teaching students appropriate lifelong information acquisition skills must become an objective.

                        - Requires knowledge, skill and appropriate attitudes

                        - Should be reinforced through routine practice

Barriers to lifelong learning

                        1989 Survey in Canada[9] (n = 909)

                                    - lack of perceived need for CNE

                                    - time constraints at work

                                    - negative impressions regarding the course

                                    - lack of confidence in relation to one's learning ability

                                    - low personal priority

                                    - professional disengagement (burnout)

                                    - cost

                        1993 Survey in Texas[9] (return rate 17.7% for n = 177)

                                    - cost

                                    - time constraints at work

                                    - travel

                                    - family and child care responsibilities

                                    - course topic

                                    - lack of employer support

                        1987 Survey[9] (n = 145)

                                    - personal confidence in performing assessment

                                    - support from employers

                                    - support from colleagues

                                    - support from nursing supervisors

                        1993 Survey in Texas[9](return rate 17.7% for n = 177)

                                    - lack of support from physicians

                                    - lack of support from nursing supervisors

                                    - lack of support from other employees

                                    - lack of support from colleagues

                                    - lack of personal confidence in performing skills

                         - job does not provide opportunity to use skills

Outcomes of Instructional methods

                        - PBL students learn to use the medical library earlier and use it more frequently than do students in traditional curricula.[3]

                        - No difference in level of library use between the faculty in PBL and traditional curricula.[3]

- Comparative survey of graduates from four PBL and five traditional curricula medical schools at graduation and two and five years post-graduation.[3] (response rate 42-55% for n = 356)

- Only significant difference was that PBL graduates preferred formal continuing medical education (CME), 14.08 vs. 13.36 on scale 0-20, compared to their counterparts from traditional curricula (p = .048)

- No significant differences between the groups in use of colleagues, biomedical literature or pharmaceutical company literature as source of information

                        - No significant differences between the groups in teaching to learn or using computers as a method for obtaining new information         

                        - Colleagues were the information source of choice - 27 on scale 0-32

- Biomedical literature was highly regarded, 20 on scale 0-32, but personal libraries were preferred to hospital or health sciences libraries

                        - Teaching to learn was valued by those who had completed their residencies

- Comparative survey of graduates from a Canadian PBL (McMaster) and traditional curricula (Ottawa) medical school.[4](response rate 53% for n = 342)  

- No significant differences in the rates of participation in reading, using audiovisual materials, teaching, attending conferences, participating in CME courses.

                        - Greater proportion of graduates in primary care from the traditional curricula medical school, 56.4 vs. 45.5%

- Residency training requires rapid clinical problem solving and residents turn to their peers for answers and not the library for rapid information acquisition

                        - Traditional curricula medical school graduates become equally proficient in medical library use during their residency

1. Successfully used in improving study skills, philosophy, nursing, graduate sociology courses, graduate education courses and medical students in gerontology courses[12]

                        - Medical students reported generally higher levels of anxiety at the start of the experience than at the end

                        - Attitudes toward self-directed learning was enhanced using the contract method

                        - Skill increased as learners attempted the tasks in self-directed learning (learned how to learn)

                        - Means of developing good habits and skills in self-directed lifelong learning in undergraduate medical education

            2. Learning Contract specifies what is to be learned, how it is to be learned, and how learning will be verified

- collaborative effort where the learner is responsible for initiating and directing the learning project and the educator aids by providing feedback rather than direction.

                        - Learning objectives

                                    Recognize desired competences, knowledge and skills

                                    Needs assessment of current skills compared to the goals

                                    Establish objectives and priorities

                        - Learning resources and strategies

                                    Identify human and material resources

                                    Develop a plan for learning

                        - Evidence

                                    Identify evidence to be used as proof of learning

                        - Validators and criteria

                                    Identify individuals to evaluate their evidence of learning and its quality (success or failure of the project)

In 1985 a cross sectional sample of physicians reviewed hypothetical case histories and were asked what treatment they would provide.[7]

                        - Physician responses were more related to their training, environment and attitude than to the latest medical trials

                        - Older physicians picked treatments that were in vogue during their training

- University hospital physicians were more likely than the community physicians to have read the recent literature but relied on discussions with peers in making therapeutic decisions

                        - Printed materials and/or Journal club rarely have a significant effect when used in isolation[11]

                        Predisposing - communicates or disseminates information

                        Enabling - facilitates the desired change (protocols, algorithms or practice guidelines)

                        Reinforcing - provides practice reminders or feedback

                        Mixed - combination of all three of the above

Review of 50 randomized controlled trials of CME programs (total of 74 discrete CME methods) with objective assessment of physician behavior or health care outcomes (Internists, General Practitioners, Family Physicians)[6]

                                    - Predisposing only CME produced a statistically significant change in physician performance in 7 of 11 trials

                                                - Printed material not effective

- Workshops or small group sessions that did not attempt facilitate physician practice did not produce statistically significant changes

- Using learning experiences with knowledge testing and needs assessment did produce some significant changes in performance

- Predisposing and Enabling CME produced a statistically significant change in 9 of 10 trials measuring physician performance and in 2 of 6 trials measuring patient outcomes

                                                - Clinical policies or practice guidelines alone had a negative effect

                                                - Protocols or algorithms coupled with printed materials and workshops were effective

                                                - Workshops with didactic presentations and practice sessions improved performance

- Predisposing and Reinforcing CME produced a statistically significant change in 18 of 26 trials measuring physician performance and in 6 of 9 trials measuring patient outcomes

- Success of feedback in conjunction with didactic presentations, printed materials, workshops or visits by academic detail persons (i.e. the pharmacist)

- Mixed intervention CME produced a statistically significant change in 14 of 14 trials measuring physician performance and in 5 of 9 trials measuring patient outcomes

-Chart review combined with opinion leaders (prominent physicians) was effective

- Most effective in changing use of diagnostics tests (10 of 11 studies), prescribing practices                                         (6 of 6 studies), primary prevention activities (5 of 5 studies)

- Clinical management and patient counseling behaviors are complex and difficult to change

                                    - Objective determination of practice and educational needs is a necessary prerequisite for effective education

Feedback and reminders can be effective but motivated individuals are required for a successful intervention and permanence of the effect is not guaranteed after withdrawal of the intervention[11]

                        Computerized decision support systems have resulted in improved physician performance[11]

                        Outreach visits and academic detailing combined with feedback have some effectiveness[11]

                        Workshops which employ practice rehearsal has been effective[11]

                                    - ability to see something in action and try it out seems to be essential for changing behavior

National guidelines are seen as more scientifically valid but are less likely to have a significant impact then locally produced ones with involvement of local opinion leaders[11]

                        Didactic teaching not effective[11]

                        Not effective for teaching motor skills, promoting problem solving or changing attitudes.[8]

80% of information forgotten in a few weeks (percentage increased when lectures are presented in series without time for recipients to assimilate the material)

                        Attention to lecture declines after 20 or 30 minutes

Suggestions to facilitate lifelong learning

            - Most important element in lifelong learning is probably the attitude toward information acquisition.[3,5,10]

                        Support the physicians, nurses and students in their educational efforts

                                    - feedback, role models, rewards for learning behaviors

            - Integrate the medical library and librarian in the medical education process as an equal team member.[3]

                        Useful for evaluating the ability to learn independently

                        Promote independent learning and problem solving

            - Integration is the most important factor in ensuring that the necessary information skills are imparted to the medical students and practitioners

            - Develop learning resource centers to promote computer literacy and self-directed learning through access to information sources[5]  

            - Needs assessment with encouragement of self-evaluation modalities

                        - should be performed on a regular basis[11]

                        - computer simulations, self assessment examinations, standardized patients, practice profiling, surveys, discussion with peers[5,10,11]

                        - In-service examinations

            - Learning contracts[10,12]

- written learning plan in which learners identify what they want to learn, the resources and methods that will be used to learn, and how they will demonstrate that they have learned

                        - incorporate in the undergraduate medical education

            - Reinforce and support the implementation of new CME and CNE knowledge and skills.[9]

            - Fix the problems with traditional CME[5,6,8,11] and CNE[9]

                        - Assessment of the participant's need

                        - CME planning to address the needs of the audience and not the interest of the speaker

                        - Relevance of knowledge - must be able to apply to real-life situations

                        - Convert passive learning into interactive learning, i.e. small group, audience discussion, rehearsal time

                                    Correlation between intensity of the educational encounter and incidence of positive results

                                    Practice based predisposing and enabling or predisposing and reinforcing activities are the most effective

                        - Efficient use of physician time and energy

                                    Speaker should synthesize information

                        - Systematic evaluation should follow every CME to determine whether participants have changed their behavior

- CNE programs should be aimed at the needs of the nurses and provide knowledge and skills that are within the scope and practice of nursing.[9]

 

References

1. Whitney M.A., Caplan R. M. Learning Styles and Instructional Preferences of Family Practice Physicians. J Med Educ, 1978 Aug; 53(8):684-6.

2. Sonnen BE, Notes on Continuing Education: Bloom's Theory of School Learning. J Contin Educ Nurs, 1981 Jan-Feb; 12(1): suppl 1-4.

3. McGowan JJ, The role of health sciences librarians in the teaching and retention of the knowledge, skills, and attitudes of lifelong learning. Bull Med Libr Assoc, 1995 Apr; 83(2): 184-9.

4. Tolnai S., Lifelong learning habits of physicians trained at an innovative medical school and a more traditional one. Acad Med, 1991 Jul; 66(7): 425-6.

5. Anderson MC, New opportunities to improve physicians' lifelong learning. Acad Med, 1996 Feb; 71(2): 115-6.

6. Davis D.A., Thompson M.A., Oxman A.D., et al. Evidence for the effectiveness of CME: A review of 50 randomized controlled trials. JAMA, 1992 Sep; 268(9): 1111-1117.

7. Morgan PP, Are physicians learning from what they read in journals?. Can Med Assoc J, 1985 Aug 15; 133(4):263.

8. Barzansky B, Foley R, Instructional considerations for CME program planners. QRB Qual Rev Bull, 1981 Jan; 7(1):17-20.

9. Turner P, Continuing nursing education: why don't nurses go? why don't they use what they learn? Nursingconnections, 1993 Summer; 6(2): 5-12.

10. Ward J, Continuing medical education. Part 2. Needs assessment in continuing medical education. Med J Aust, 1988 Jan 18; 148(2):77-80.

11. Young Y, Brigley S, Littlejohns P, et al., Continuing education for public health medicine - is it just another paper exercise? J Public Health Med, 1996 Sep; 18(3):357-63.

12. Fox RD, West RF, Developing medical student competence in lifelong learning: the contract learning approach. Med Educ, 1983 Jul; 17(4):247-53.

13. Finestone AJ, Brigham MP, Strony J, et al., Can medical school admissions criteria identify lifelong learners? Pa Med, 1982 Feb; 85(2): 22, 24, 33.

14. Bell F, Rix P, Attitudes of nurses toward lifelong learning: one hospital examines the issues. J Contin Educ Nurs, 1979 Jan-Feb; 10(1):15-20.

15. Bligh JG, Independent learning among general practice trainees: an initial survey. Med Educ, 1992 Nov; 26(6): 497-502.

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