HOW MUCH DO YOU KNOW ABOUT: PHYSICIAN LEARNING TECHNIQUES

How Physicians Learn 

There are many theorists who have described learning. Bandura’s social cognitive theory (1986) links the individual’s personal factors with environmental/situational factors and behavior. Other theorists such as Schon, Knox, Cross, and others share the view that the individual is self-monitoring, capable of goal-setting and achievement. They conclude that because each individual is unique, internal and external influences will impact the motivation of each individual’s pursuit of self-directed learning. Some of these factors include perception of need, curiosity and professionalism. Environmental factors may include the availability of information, interaction with colleagues, community expectations and integration into practice. Newer learning theories (Brown, et al 1989; Grow, 1991) are now taking into consideration utilizing a “guide to practice” model for physicians. This would involve situated learning, based upon the concept that knowledge resides in practice, and the physicians may better learn by doing techniques over and over in the presence of experts. Essentially, an apprenticeship model is used where there is greater educational oversight, support and feedback initially which is gradually lessened until the learner can complete the process alone and free standing. Most physicians want to continue to learn and adapt their practice behavior to use new technologies and therapeutic agents to improved patient care and outcome. In the ideal model, the process begins with a self-determined need for new information or competence. The impetus may be a specific patient problem or an interest in the developments in their particular field of practice. The next step is to seek the new information or technical skill. Physicians will seek to gain this new information either informally or in a more structured setting. Physicians willing to adopt a new practice or use of a therapeutic agent are more likely to change if the change can occur autonomously. If there are no barriers (perceived or real) to implementing a new practice behavior based on the information or technical skill, the physician will adopt and incorporate this change into their practice. However, today’s healthcare environment with many physicians in group practices or employees of healthcare systems may encounter organizational barriers. It is essential to understand the environment in which the physician is practicing to plan and deliver "change-enabling" CME.

Documented Methods by Which Physicians Want to Learn

Physicians "routinely" learn in a self-directed manor utilizing journal articles or through attendance at association/society meetings. Other methods of learning occur when physicians encounter either a practical problem or a theoretical one. When a patient presents with a difficult problem, the physician searches immediately for a reliable resource. The physician will usually perform a literature search, seek out experts in the field or consult with colleagues to learn how others handled a similar problem. (practical)

In general, when a physician wants to update current knowledge or develop/enhance a particular skill, they tend to choose formal learning such as attendance at conferences, meetings, symposia, etc. (theoretical).

There are gender preferences in the structure of the formal learning activity. Because married female physicians are more likely to be responsible for childcare, they prefer live activities that are held on the weekend in "family-friendly" locales. Female physicians are less likely to attend social activities included in the activity, again, due to family responsibilities. Male physicians tend to prefer an educational structure that includes a social event for networking and personal case discussion. Both male and female physicians want interactive discussion of the clinical aspects of the topic to be included in the activity, while female physicians prefer to include psychosocial aspects of patient care as well.

All physicians expect data that is peer-reviewed and presented by recognized opinion leaders in the field. All physicians share a significant barrier: little protected time for learning.

Effective CME Methodologies

The most effective CME is that which provides physicians with useful information that can be immediately applied to their practices. It has been shown that an activity that is simply dissemination of information with no feedback from participants results in little change in physician behavior. The specific delivery can take many forms:

Activities that include active participation by the attendees can result in significant changes in physician practice. Use of vignettes, case studies, interactive workshops, small group and individualized training sessions as well as the use of audience response systems in large group settings are suitable methods to achieve participation.

Role-play, case discussions and hands-on practice are quite effective as well.

Another strategy that can increase the probability of physician change is to provide "enabling" tools such as: patient education materials, or specific forms or processes used successfully in other practices.

Involvement with the physician in a variety of ways also increases the likelihood that the change will be successful and long-lasting. Such interventions can include reminders/prompts via e-mail or other method and provision of additional educational materials such as peer-reviewed web-based sites for topic-related articles.

Providing an application forum at the conclusion of an activity can assist physicians to determine what will be effective and what will hinder them in putting the learning into practice. This can be done as small group forums or more individualized planning.

Encouraging attendance as a practice group to increase the likelihood of "buy-in" and subsequent change in physician practice. Use of vignettes can provide a practical application of learning.

New Technology for CME

The Internet is the new technology for CME for the foreseeable future. The advantage to web-based learning is that it can be accessed 24 hours/day, 7 days a week from anywhere in the world. There are some challenges to conquer for this medium to be truly productive and conducive to physician learning. Some of these will be accomplished over time as the technology advances and becomes more sophisticated and easier to use.

Many older physicians are utilizing the net to keep current on the articles that their patients bring in during office visits but haven’t quite mastered the skills necessary to utilize web-based CME. Most new medical residents, on the other hand, utilize handheld devices while making rounds to look up drug interactions or practice guidelines. These doctors of the future are very comfortable with using the Internet and will expect more than the recreation of print material on-line. Physicians will demand more web-based CME but it will still need to provide case based learning and the ability to share experiences with peers.

One new, web-based method being further developed for physician CME is the concept of “Point-of-Care” education, where a physician would have immediate web access to evidencebased information for resolving patient care issues quickly, while still receiving CME credit for this internet educational activity. This form of education would also encourage interaction between peers and the exchange of information, geared toward improving patient outcomes (Leung, 2003; Pelletier, 2004).

Another technology is the use of CD-ROMs. These can be used as an enduring activity or as collateral take-home materials at a live event. Interactive video conferencing and satellite broadcasts can be very successful particularly for rural physicians, those with travel limitations, or those who want their entire practice to attend.

Case Studies: How We Used CME to Change Physician Behavior

Assessing Impact of CME

In order to facilitate retention of learning from an activity, frequent reminders are helpful to the physician. These can be in the form of evaluations, reflective emails, and outcome studies. Outcome studies--often conducted at 6 and 12 month intervals--measure the impact of the activity over the course of the year. In addition, it affords another opportunity to remind the physician of the information learned at the activity.

Conclusions

Effective CME occurs as a result of understanding how and why a physician makes changes in the way they practice. Physician motivation, needs and clinical setting variables need to be considered. In addition, understanding human behavior, change theory and adult education strategies produce effective CME

There are many factors impacting the provision of CME. The major forces include: Reimbursement, regulations and licensure, certification, specialization, managed care systems, technological and medical evolution, the increasing age of the elderly, the general economic environment, and the way in which physicians now practice in group practice rather than as solo practitioners.

The important elements to remember are that the CME must have relevant content; it must be easily accessible; and the learner should be able to collaborate in some way (case study responses, chat room for discussion, e-mail colleagues, etc.).

The challenges for all of those involved in the provision of CME are to assess physician need and to base the specific method of delivery on those needs. In addition, measuring the efficacy of the CME is an integral part of future CME planning.