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* From the Department of Neuroscience, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, ND.
Correspondence to: H. B. Slotnick, PhD, PhD Department of Neuroscience, School of Medicine & Health Sciences, 501 N Columbia Rd, Grand Forks, ND 58203; e-mail: slotnick{at}medicine.nodak.edu
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Abstract |
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 TOP Abstract IntroductionPhysicians’ Learning...Learning Resource UseRecommendationsSummary and ConclusionsReferences |
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Key Words: adult learning • learning theory • physician learning
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Introduction |
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TOPAbstractIntroductionPhysicians’ Learning...Learning Resource UseRecommendationsSummary and ConclusionsReferences |
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Physicians’ Learning Episodes |
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TOPAbstractIntroductionPhysicians’ Learning...Learning Resource UseRecommendationsSummary and ConclusionsReferences |
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There is also a set of patterns called learning episodes that describes the stages doctors move through in going from the specific and general problems that precipitate learning to learning outcomes. These stages have been described by Fox and his colleagues,6 7 as follows: (1) doctors deciding whether to take on a learning task; (2) learning the skill and knowledge anticipated to resolve the problem; and (3) gaining experience using what was learned in a variety of settings.
This formulation has recently been expanded to make it more congruent with doctors’ clinical learning activities.8 The first change was the addition of a fourth stage (scanning), in which doctors examine their environments both for problems that might precipitate learning and for ideas, proposals, etc., that may be useful to them in the future, although they have no immediate need for them.
The second change concerns the manner in which the remaining three stages are manifest as a function of the type of the precipitating problem. In particular, specific problems progress rapidly and make use of immediately available learning resources, while learning associated with general problems is more deliberative and uses immediately available resources as well as those requiring more effort before they could be accessed (eg, courses at specialty society meetings). The issue of which resources are used as a function of problem type and stage will be considered later in this article.
The third change is the addition of clear, although unstated, criteria used to describe whether learning should continue on to the next stage or should terminate (which means the physician returns to the scanning stage). The four stages are presented as a function of problem type in Table 1 .
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Summarizing to this point, the existing literature on how doctors learn makes three claims:
1. Physicians’ self-directed learning activities vary with both the nature of the problem precipitating the learning episode and the stage the doctor is at in resolving the problem.
2. Stages in self-directed learning episodes are distinguished from one another in terms of their goals, discrepancies, learning resources, reflection, and criteria for completion.
3. Self-directed learning episodes can terminate for reasons that may or may not be justified. The doctor then returns to the scanning stage.
Left unresolved is the question of where doctors turn for skills and knowledge they need to complete each stage, the question considered in the next part of this article.
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Learning Resource Use |
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TOPAbstractIntroductionPhysicians’ Learning...Learning Resource UseRecommendationsSummary and ConclusionsReferences |
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Left unresolved is the question of which resources doctors use to find the skills and knowledge needed to address general problems. Answers to this question arise from the preliminary findings of study of physicians’ learning resource use.13 A random sample of North Dakota physicians were asked to indicate which resources among a list of 43 a physician would use to find solutions to a general problem (ie, updating) with problems arrayed along two dimensions: (1) stages of learning episodes (note that scanning was not included since it is done "intuitively" and so considers all resources a doctor might encounter); and (2) the nature of the general problem precipitating learning (ie, updating on a commonly seen disease, updating on a commonly used diagnostic approach, updating on a commonly used therapeutic approach, and updating on a commonly used therapeutic technique). Thus, the study was able to address questions including the following: Which resources are commonly used in addressing a variety of general problems? Is there a difference in the number of resources used moving from one episode stage to the next? Is there a difference in the number of resources used for addressing different varieties of general problems?
Preliminary findings from the study suggest that the resources doctors use to address general problems are the same as those used for specific problems (ie, talking with same specialty colleagues, and reading journals available in the doctors’ offices), augmented by some that are not immediately available and so are not used in solving specific patient-care problems (ie, attending specialty society meetings, talking with doctors at such meetings, and journals available at the medical library as opposed to those in the doctors’ offices). These findings make sense; the lack of immediacy associated with general problems means that doctors can use resources that require planning before they can be accessed.
Preliminary findings also suggest that the number of resources used varies with the general problem varieties and stage, although the statistical interaction observed to exist between these two factors complicates interpretation of findings. Examination of the interaction suggests the following:
1. Regardless of problem variety, the smallest number of learning resources are at the gain experience stage. Smaller numbers of resources are likely needed, since this is a largely experiential activity; while it is true that physicians value sharing experiences with other doctors, it is also true that a doctor needs to gain and reflect on experience if he or she is to internalize it. This is true across all problem varieties.
2. More learning resources are used at stage 1 (evaluating the problem to decide whether to learn to solve it) and stage 2 (learning the skills and knowledge) for a disease update than updating on a therapy or a diagnosis. The problem varieties vary across both stages (evaluating the problem, and learning the skills and knowledge) in terms of the numbers of resources used. It is likely that more resources are needed for updating on disease than on diagnosis or therapy because information on disease tends to be developed in and to be available from research centers, while information on diagnosis and treatment is more likely locally available.
3. While the number of learning resources is generally the same for both diagnosis and therapy, there is a small but statistically significant difference between therapeutic approach and therapeutic technique, the difference being that fewer resources are needed to learn the skills and knowledge for the therapeutic technique than for the therapeutic approach. The interaction of therapeutic approach vs therapeutic technique with stages indicates that learning the skills and knowledge associated with the technique requires fewer resources than the approach, probably because one learns how to do something (technique) by doing it, and one learns about an approach by reading and discussing what one reads with others, such as colleagues.
In summary, there are differences in the resources accessed in resolving general problems, and the differences are very much a function of both the problem the doctor is learning to solve and the stage the doctor at while learning the solution. The implications of these findings are the subject of the last section of this article.
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Recommendations |
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TOPAbstractIntroductionPhysicians’ Learning...Learning Resource UseRecommendationsSummary and ConclusionsReferences |
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It has long been known that adults, generally,14 and physicians, specifically,15 learn in response to problems they perceive they have. It is now clear that simple recognition of a problem, while necessary to ensure learning, is not sufficient in and of itself. First the doctor must evaluate the problem to decide the following: (1) if it is really is a problem he or she should handle; (2) whether the problem likely has a solution; (3) whether the resources needed to resolve the problem are available; and (4) once learning has taken place, whether he or she is prepared to change his or her practice in order to solve the problem that precipitated the learning.8 The recommendation for those who would teach doctors is that they must first provide information allowing learners to decide whether to take on the learning project, since proceeding directly to teaching the skills and knowledge may be entirely premature. An example will show how this works.
There is currently concern about the use of pulmonary artery catheters.16 17 18 19 20 If one wishes to change practitioners’ use of the catheters to resolve these concerns, one must first convince these same practitioners that learning the required skills and knowledge is indeed going to help them solve problems they already recognize they have.19 Recall that the first criterion doctors use in stage 1 (evaluating the problem) is, Is this a problem for me? Therefore, knowledge of the problems potential learners face in their practices and ways they approach them is simply a necessity.
Similarly, it appears that doctors likely use the same resources in evaluating the problem and in learning the skills and knowledge required to complete the stage of learning they are at. Since the criteria are different at each stage (see Table 2 ) while the resources are often the same, it is clear that the ways in which doctors use resources at each stage is different. The recommendation for anyone who would teach practicing clinicians is that the doctors in their audiences are looking for different things from the presentation they are seeing, depending on where they are in the learning process; pointing out the applicability of what one is teaching for those at each point in the learning process helps ensure that the needs of different audience segments will be met.
Finally, there is the issue of documenting the outcomes of learning, and this leads to two recommendations. Recognizing that each stage can end in two ways (move on to the next stage vs terminate learning and return to scanning), and that the decision can be either justifiable (the basis for the decision is "valid") or unjustified, documentation of learning outcomes needs to consider the four possibilities shown in Table 3 . Recall that the criteria doctors use for ending each stage in a learning episode are practical vs theoretical. This means that justification of a doctor’s actions can only be made by looking at what the doctor did (eg, how the doctor ended the learning episode), and the doctor’s criteria for making the decision that resulted in the action taken. The first recommendation, then, is that anyone who evaluates educational activities for physicians should note both how each individual doctor (1) moves from one stage to the next or ends the learning activity, and (2) why he of she took the action that was undertaken.
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Summary and Conclusions |
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In contrast, general problems require more deliberative behavior from the doctor and make use of learning resources that require planning to access, as well as those that are readily accessible, applicable, and familiar. The resources include professional meetings and materials in the medical library. Learning resource use also varies from stage to stage (more resources are used in evaluating the problem and learning skills and knowledge than in gaining experience) and from one variety of problem to another (eg, learning-resource use is greater for the first two stages for disease updates than diagnosis or therapy updates.
Finally, successful interventions to change doctors’ behaviors need to consider both of the stages that the doctors move through, and the ways in which doctors will use learning resources at each point.
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References |
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