How do physicians identify a need for learning?

How do physicians identify a need for learning?

In my previous post, I introduced some of the key tenets of adult education (andragogy) and how these can influence instructional design. How do physicians find the time for CME, though? Imagine the following, and place yourself in this newly qualified doctor’s white coat.

My days are stressful and hectic and there is never, ever enough time for all of the things that I want to do. I start the day by looking at my schedule, which, as usual is fully booked with patients scheduled at precise intervals of fifteen minutes. Even at this early point in my day, I can already feel my anxiety levels rising. My 7:30 a.m. appointment shows up at 7:44 – literally seconds to spare before being over our fifteen-minute late policy. By the time the patient checks in and is in a room waiting to be seen, it’s well after 8:00, and I can see my later patients arriving already through the glass doors. It is going to be busy day for us all as it is flu shot season.

I feel the pressure of people waiting, but when I go into that first room, I can’t bring myself to rush this elderly patient who’s worried about her diabetes. I sit down, try to control my rising anxiety, focus and listen to what she has to say. I know that she lives alone and is originally from out of state. Her support network is nonexistent, and she likes to chat during our scheduled visits. Meanwhile, I’m trying to find out, what were the results of the emergency room tests? What were the results of the tests we ordered last time? What did the Diabetologists do? I ask these questions, knowing that the clock above my head is ticking away. I have been seeing a lot of patients with diabetes who are struggling to control their numbers… I am wondering if the advice I am giving is relevant… there might be a better way to help…

A chance remark by the office manager reminds me of my time at Medical school where my training and days had a relative structure – now I feel as though I am left to fend for myself and seek out education and training that is relevant to me and my patients. I think this is a good thing, but the more I think about the more anxious and overwhelmed I become.

All of my scheduled patients show up, I spend the morning running from room to room and my designated lunch hour is reduced to fifteen minutes. I was able to ask a colleague advice on a matter I had seen earlier on in the day over a slurp of (cold) coffee. She suggests an article for me to follow up on, I will try to find it later. By the end of the day, I’m physically and emotionally exhausted. I am reminded as I leave by a colleague that I missed a live webinar on Asthma control in teens during my lunch break. I leave the office and start preparing myself for tomorrow’s day, thinking that I would like to review that webinar… but also need to shop, and eat. I also feel proud of my efforts today, and I love the fact that I am a PCP.

Phew—what a day!

  • How are you feeling?
  • Are you ready to sit down and learn all the things that you want to?
  • Are you focused?
  • Are you clear on your learning goals and areas of development?
  • Have you decided what you are going to have for dinner?

The above description shows numerous potential areas for development . . . but how do physicians even get to the stage of deciding on what CME venture to embark on?
The tenets of andragogy are useful and applicable—as instructional designers, we just need to help our physician-learner get there.

As always, looking at the literature will help us—physicians are, after all, adult learners.

The Change Agents of Learning


The first stage of the learning process occurs when physicians scan their environments and become aware of some element of their practice that may require an educational intervention (Slotnick, 1999). Elsewhere in the literature, Grol (2002) calls this the process of orientation. In other words, the condition of becoming aware of and interested in a potential change and having knowledge, understanding, and insight into the characteristics of the prospective change.

Interestingly another, form that the change process takes comes from reflection. Geertsma et al. (1982) refer to this as priming, namely, when physicians sense dissatisfaction with some aspect of their practice—which, in turn, signifies a sense of cognitive dissonance resulting from a perceived discrepancy between what they are actually doing and what they believe they should be doing related to their performance. In addition to this, physicians can, and very often are, driven to undertake learning after receiving feedback from external sources. From this we can see that both scanning and priming are important predecessors to the decision-making procedure, which will inform the instigation of learning.

Further to this, the scanning stage of learning can very often include physicians proactively looking for problems or issues that may inspire and/or subsequently cause learning. Sometimes they may identify an issue or discover an idea that they think may become necessary to learn about in the future, but that may not warrant pursuing at the present time for their current situation (Slotnick, 1999, 2000).

This aspect of the scanning stage reflects a physician’s awareness that he or she needs to be alert for problems that are potentially available on the periphery. If the physician reviews a wide enough range of clinical concerns, he or she is highly likely to ascertain areas that are prime for learning (Geertsma et al., 1982).

Focusing and Evaluating the Need


Slotnick developed this process further (1999; 2000) and identified a set of questions physicians may ask themselves when determining whether or not to pursue an area of potential learning:

  • Is there really a problem?
  • Is this a problem for me?
  • Is there a likely solution to the problem?
  • Are resources available to learn what is required to solve the problem?
  • Am I prepared to make the changes in my practice required by the learning I do?


Reformulating the identified problem in the guise of a question can help clarify whether the issue is indeed relevant and if an answer is readily available. The question may involve a simple determination, such as what insulin to use for a specific patient, or it may involve a more complex question such as what options are available to manage hypertension in diabetics.

What happens next?


From the above, it can be summarized that medical professionals very often recognize that any learning can very often lead to changes in their working lives and practice.

Therefore, they must consider how prospective changes may affect them personally and/or professionally, and whether they are prepared, or wish, to make changes associated with the learning they complete (Slotnick, 2000).

Thinking again back to the beginning of the post, we can see that physicians need to be judicious and discerning in their pursuit of CME. Realizing that there is a manageable and applicable need for education is the first step—and this is certainly the case for our newly fledged PCP. The next step in the process is engaging in learning and this will be the focus of my next post.

References

Geertsma RH, Parker RC Jr, Whitbourne SK (1982) How physicians view the process of change in their practice behavior. J Med Educ. 57(10 Pt 1):752-61.

Grol R, (2002) Changing physicians’ competence and performance: finding the balance between the individual and the organization. J Contin Educ Health Prof. 22(4):244-51.

Slotnick HB, (1999) How doctors learn: physicians’ self-directed learning episodes. Acad Med. 74(10):1106-17.

Slotnick HB, (2000) Physicians’ Learning Strategies Chest. 118;18S-23S.