Knowledge Translation in Health Care - 3.5.2: Educational interventions

Dave Davis, MD
Association of American Medical Colleges

Nancy Davis, PhD
National Institute for Quality Improvement and Education

Section Overview

What is education?

  • AMA defines continuing medical education (CME) as: "any and all ways by which physicians learn and maintain their competence"
  • Broad and holistic definition, but...
  • CME often involves large group sessions that rarely demonstrate evidence of effect on clinician performance or health care outcomes
  • We describe educational interventions to promote the use of best evidence into health professional practice

What are the purposes of education?

External forces for change:

  • Knowledge explosion
  • Specialty society interests in CME
  • Need for documenting knowledge and skills maintenance
  • Pharmaceutical and commercial interests in influencing physician practice
  • Innate professionalism

Internal forces for change:

  • Recent personal experience
  • Changing demographics (e.g. aging or changing populations and patient demands)
  • Self-appraisal and awareness built from clinical experiences
  • New and expanded competency or "zone of mastery"

Types of change:

  • Small adjustments or accommodations (e.g. adding a new drug to a regimen)
  • Larger redirections (e.g. adopting an entirely new method of practice)

Traits of the self-directed learner:

  • Discipline and motivation
  • Analytic abilities
  • Ability to reflect and be self-aware
  • Curiosity, openness and flexibility
  • Well-developed information-seeing and retrieval skills
  • Good general learning skills

(Candy, 1991)

What is the process for education?

Steps in the change process:

  • Rogers' "decision-innovation process"
  • Prochaska and Velicer's "transtheoretical model"
  • Pathman's "awareness-agreement-adoption-adherence" process
  • Stages of learning important in studying effect of education interventions
change continuum
Awareness Agreement Adoption Adherence
Elements of change: Predisposing elements: Enabling
Reinforcing elements:
Possible roles for educational interventions Conferences, lectures, rounds, print materials Small group learning activity; interactivity in lectures Workshops; materials distributed at conferences; audit and feedback Audit and feedback; reminders

Using only one technique rarely produces change, but...

  • Awareness of new evidence, conferences, print materials and rounds may predispose to change
  • Exposure to other learners at conferences may provide a setting for discussing new findings or guidelines
  • Workshops or on-line learning experiences may facilitate adoption of new methods
  • Audit/feedback may facilitate sustainability

What educational interventions can we use?

Large group sessions produce little performance change, but...some useful and effective strategies to increase impact on performance and health care outcomes:

  • Determining needs and setting objectives
  • Formatting the large group session
  • Variation in the educational method

Determining needs and setting objectives:

  • Driven by patients and health care system, not just needs of learners
  • Subjective needs assessment strategies (questionnaires, focus groups, structured individual interviews, and diaries or log books)
  • Objective tools (standardized measures of knowledge and/or skills, chart audits, peer review, observation of practice and reports of practice patterns and physician performance data

Improve formatting of large group sessions by:

  • Employing multiple methods
  • Increasing interactivity of the sessions
  • Using other strategies to increase reach and impact

Employing multiple methods:

  • Use a variety of presentation media

(e.g., audio tapes; actual or standardized patients or videotapes; panel discussions;
debates; quizzes on learning needs or outcomes)

  • Distribute practice enablers

(e.g., patient care reminders, protocols and flow sheets, patient education materials, wall charts)

  • Use clinical scenarios and vignettes to increase relevance and applicability of materials
  • Staging two workshops instead of one

(e.g., one month apart)

Increasing interactivity of the sessions:

  • Increase the frequency and duration of Q and A sessions
  • Encourage "buzz groups" and pyramiding or snowballing techniques (e.g., think-pair-share)

Small group learning:

  • Groups of 5-10 learners who meet regularly
  • Led by a facilitator
  • Common in Canada and Europe
  • Demonstrate an impact on competence and performance (possibly due to concentration on evidence-based material, peer pressure and influence)

Distance education techniques:

  • Web, video, or audiocasts
  • Must be interactive to engage the learner
  • Have shown increases in physician knowledge and knowledge retention
  • Online communities of practice (promotes networking and consulting among peers)

Self-directed learning:

  • Traditional textbooks, monographs, clinical practice guidelines, and journals supplemented by...
  • Printed or computerized self-assessments that provide feedback
  • Portfolio-based learning (document learning, quality of learning, learning gaps, examples of learning plans, objectives and resourced required)

What are some current trends in CME?

  • Changing construct of CME (no longer just information transfer)
  • Need for rapid response educational technologies for new and emerging disease states
  • Improved chronic disease management
  • Maintenance of licensure and certification (focus on demonstration of improved practice)
  • Increasing focus on health care outcomes and performance

Outcomes for continuing education/continuing professional development

Level Outcome Metrics or indicators
Patient health
Population health
Participant satisfaction
Changes in knowledge, skills, or attitude
Changes in practice performance
Changes in patient health status
Changes in population health status

Future research

The learner...

  • Are self-assessment and self-directed learning core character logic traits or can they be taught?
  • If the latter, how can this best be accomplished?

The communication vehicle...

  • What knowledge transmission vectors work best? (PDA-mediated educational messages vs. traditional educational ones)

The context of learning...

  • The seeing of learning, its remuneration pattern, and its linkage to IT resources

The effect on learning and uptake…
How is the uptake of information effected by the nature, complexity, compatibility and level of evidence to be adopted?

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