Applying Adult Learning Principles

1. Applying Adult Learning Principles Society for Academic CME April, 2003 Santa Fe, New Mexico Joseph S. Green

2. Operational Functions Certifying activities Designing, implementing and evaluating activities Documenting credit for physicians Academic CME Functions Linking to quality data and physician performance measures within health system Working across the continuum of medical education Assisting school in assuring regulatory compliance Undertaking CME research Initiating faculty development focused on learning and leadership Medical School CME

3. Current Status Duke Office of CME (as of January 2003): • Operational Functions--90% of staff effort and 12+f.t.e. • Academic CME-- 10% of staff effort;5% of Medical Director and 25% of Associate Dean; 0 f.t.e.

4. Survey of SACME % of time spent on Academic CME • 0- 25% • 26%-50% • 51%-75% • 76%-100%

5. Survey of SACME If 0-25%, • 0-10% • 11-15% • 16-25%

6. One Example of Academic CME Activity: Applying Adult Learning Principles to Undergraduate Medical School Curriculum: Working Across the Continuum to Enhance Physician Competence

7. Does Your Medical School CME Office Contribute to the Continuum of Medical Education ? • ( ) Have never thought about it • ( ) Have considered it, but have never done anything • ( ) Have started to contribute • ( ) Have on-going project(s) with either UME or GME or both • ( ) Have absolutely no idea what you are talking about

8. Why is there a need to Collaborate Across the Continuum of Medical Education? • Closer tie to the primary mission of a medical school • Adds value to the contribution of the CME Office • Allows more visibility for the CME Office for other contributions later • Brings experience with Adult Learners to the undergraduate curriculum

9. Characteristics of Adult Learners Duke School of Medicine Curriculum Revision Project Joseph S. Green, Ph.D. Associate Dean, CME January, 2002

10. The Setting • UME Curriculum Revision Project Committee Meeting • 45 physician faculty committee members • Chair of Curriculum Committee moderated session • 1 and ½ hours • Started at 5:30 pm • Light snacks and soft drinks provided • No ‘advance warning’

11. Learning Objectives At the conclusion of this session, members of the curriculum committee should be able to: • Articulate the implications of the new vision of physician lifelong learning • Provide a rationale for shifting the paradigm of how a medical school curriculum is designed, implemented and evaluated • Articulate differences between learning for children (pedagogy) and adults (andragogy)

12. Learning Objectives (con’t) At the conclusion of this session, members of the curriculum committee should be able to: • Discuss the theoretical foundations of adult learning principles. • Recognize best practices in current curriculum • Create practical suggestions for enhancing the new, new curriculum based on ten characteristics of adult learners

13. The New Vision for Clinician Life-Long Learning and CME Joseph S. Green, Ph.D. Associate Dean, Kathryn M. Andolsek, M.D. M.P.H. Medical Director, Duke University School of Medicine Office of CME (DOCME) January 16, 2002

14. Forces in Health Care Pushing Accountability • Evidence-based care • Intolerance of variation • Demanding customers • The information revolution • Systems awareness

15. Two Landmark IOM Reports • To Err is Human: Building a Safer Health System--1999 • Crossing the Quality Chasm: A New Health System for the 21st Century--2001

16. Why is ‘life-long learning’ important to physicians and other clinicians?

17. Physician Education • Medical School (UGME) • Residency (GME) • Life-long (CME)

18. Maintenance of Certification Will require evidence of: • Professional standing • Lifelong learning and periodic self-assessment • Cognitive expertise • Practice performance evaluation Adopted by ABMS March 2000

19. Evidence of Lifelong Learning • “Certified” CME--some specialty specific • Self-assessment examinations • Participation in quality improvement • Self-directed learning • Documentation of competence

20. Competencies Expected Throughout Physician’s Career • Patient Care • Professionalism • Interpersonal and communication skills • Medical knowledge • Practice-based learning and improvement • Systems-based practice Adopted by ACGME 1999

21. NEXT PARADIGM SHIFT: Medical Education • From: Treating medical students as dependent, young learners needing constant oversight and direction • To: Working with medical students as colleagues and helping them become lifelong, adult learners

22. Goal of Curriculum Revision Project Design learning centered around not only faculty interests, expertise and a curriculum, but also on the needs and experience of the learners...

23. Descriptors of Your Early Education as a Child How would you characterize it??

24. Descriptors of Your Continued Learning as a Professional How would you characterize it??

25. Theoretical Foundations • Pedagogy: Teacher-centered learning for children • Andragogy: Self-directed learning for adults • Fluid intelligence: making new neural connections without any base (children) • Crystallized intelligence: new learning grows like crystals on existing knowledge

26. AGE 9 20 40 60 Fluid Crystal 85% 15% 62% 38% 40% 60% 25% 75% Theoretical Foundations

27. Ten Characteristics of Adult Learners Acronym to remember them: KUDE SULDAT

28. KLink new Knowledge to previous experience • Growing reservoir of experience-basis of learning • Connected to physical and psychological maturity • Target of learning must be part of integrated whole-how it fits with current situation of learner

29. UNeed to Understand what they don’t know and have a clear vision of what should be achieved • ‘I don’t know squared’ syndrome • Test about what is valued—application to medical practice, not esoteric facts • Gap between current and ideal performance is motivation for learning • Too large a gap= aversion to learning • Too small a gap= no motivation • Goal: Medium size gap= achievable

30. DDesire involvement in the learning process • For learning to occur, learner must be: • Alert • Attentive • Engaged in the process • How to assure engagement? • Involve learner in tasks that require application of knowledge to patient care

31. Learning by Doing “ He has to ‘see’ on his own behalf…the relation between means and methods employed and results achieved…Nobody else can see for him and he can’t see just by being told…” The Theory of Inquiry John Dewey, 1938

32. ESeek Environment that encourages critical self-reflection & peer collective inquiry • Adults use self-diagnosis model • Identify desired competencies • Engage in objective self-assessment • Measure the difference • Evaluate peers’ performance • Peer collective inquiry-safe and effective • Reflection • Return to experience • Attend to beliefs, feelings and values • Re-evaluate experiences

33. SHave moved self concept from dependence to Self-directedness in the pursuit of knowledge • Taking responsibility and being accountable for one’s own learning • Need to move away from unequal status of teacher and student • Major goal needs to be to help students become professionals and lifelong learners • “Autonomy and paternalism are wrong…” Frankford, 2000 • Extensive indoctrination in one problem- solving strategy…

34. Medical Model History & Physical Evaluation Diagnosis Implement Rx Treatment Plan

35. Professional Educational Model Needs Assessment Evaluation Objectives Implementation Design

36. Curriculum Design Process • Strategic Goals (Competencies) • Needs assessment of learners • Learning objectives • Content and faculty • Sequencing • Formats, methods and media • Assessment of learning/evaluation of curriculum

37. UUndertake mechanisms for obtaining feedback on performance and reinforcement of learning • Success in achieving objectives facilitates further learning • Require performance and give timely feedback • Performance measures need to be objective, valid, reliable and important • Major learning objectives need to be reinforced over time

38. LHave an innate ability toListen, Learn and remember • Effect of stress levels • Respond negatively to artificial time pressures • Learning enhanced by moderate levels, but reduced by excessive stress and anxiety • Multi-tasking-smaller bits of information • Memory:sensory,short-term,working and long-term

39. DProcess information through multiple sensory channels with Different cognitive styles • Styles related to senses: auditory, tactile, visual • Learning style inventories (LSI)

40. AAddress practical problems with useful and immediate Applications • Have problem orientation; need immediate application • Affected by current situational role • Relevance of information to practice of medicine is critical

41. TNeed skills to learn outside of structured Teacher-centered settings • Need to endow students with motivation and skill to maintain competencies, acquire new ones and commit to values • Learning how to deal with new situations never before seen (zone of indetermanance) • Independent decision-making is the ultimate goal

42. Questions?

43. Multi-Stage Physician Change ProcessRogers, 1983 • Physician learns about innovation- Opinion Leaders • MD is persuaded to think about it • Decides to “try” the change • Confirms the change was appropriate • Continues to use it

44. Curriculum Implications • Modeling behavior • Use of case-based approach • Standardized patients • Patient simulator • Role-playing • Audio and videotape feedback • Peer review • Learn to teach/teach to learn

45. Curriculum Implications (con’t) • Testing to facilitate and evaluate learning • Self-assessment instruments • Pre-tests and advanced organizers • Articulated goals and objectives • Problem-based learning • Provide opportunities for practice • Use multiple formats, methods and media

46. Acronym: KUDE SULDAT Or…

47. DUKEADULTS

48. How could you use this information to assist in your collaborating across the continuum of medical education?

49. A Resource: Would you like to use or modify this presentation for use in your setting? Go to Duke Office of CME (DOCME) Web site at: www2.mc.duke.edu/docme

50. Barriers to Academic CME • Awareness of institutions and physicians • Lack of support from Dean’s Office • Funding decreasing from institution and increasing from industry • Lack of adequate staff (numbers and skills) • Magnitude of required regulatory documentation