Provider Education and Behavior Change michael wilkes, md, phd professor of medicine and medical education university

1. Provider Educationand Behavior Changemichael wilkes, md, phdprofessor of medicine and medical educationuniversity of california

2. PROBLEM • Proliferation in volume and complexity of biomedical knowledge and technology • Increased clinical pressures including documentation, volume, and monitoring • Physicians need to maintain currency but don’t know how

4. Adult Learning Michael Wilkes

5. Instructional Design Principles • The best instruction is that which is: • Effective - facilitates learners’ acquisition ofthe prescribed knowledge, skills and attitudes • Efficient – requires the least possible amountof time necessary for learners to achieve theobjective • Appealing – motivates and interests learners,encourages them to persevere in the learningtask • Enduring– encoded in long-term memory,accessible and applicable in the future

6. Arteries and veins • Arteries: • Are more elastic than veins • Carry more blood than veins • Are less elastic than veins • A and B • B and C

7. What is the goal of learning? • Facts are important (chess, surgery, math) • Usable knowledge is not the same as disconnected facts; • Need connections and organization to promote transfer to other contexts rather than just memory • Why do arteries and veins have those properties? Know structure and fx

8. Knowing • Humans are goal directed and seek information • We come to education with prior experiences, knowledge, beliefs, etc. • This impacts what we notice and how we organize it • Which impacts how we remember, reason, solve problems and acquire new knowledge

9. Ways to earn CME Most common: live conference

10. Ways to earn CME • Live Courses • In-hospital programs • Pharm sponsored meetings (Pri-Med) • Enduring Materials (DVDs), Journals • CME Online (new guy on street both synchronous and asynchronous) • “Just in time” apps

12. Three Teachers • A: Teacher’s goal to get doctors to use Shared Decision-making skills (oversees and monitors work – focus on product and process) • B: Gives lectures and exams - assumes responsibility for learning (attends to what students are learning and monitors) • C: Give students objectives/competencies and leaves learning to students to self assess (available for feedback and consultation)

13. What is being learned? • Teacher A? • Teacher B? • Teacher C?

14. Learning • Teacher A (hospital system): • Learning to do tasks and turn in material on time but the timeline and task may get in the way. • Teacher B (CME): • Working to provide information in lectures and document recall. • Teacher C (adult learning): • learning is outgrowth of what is needed – most of this work is done before the exercise

15. Principles of Andragogy Adults • Need to be involved in the planning andevaluation of their instruction. • Need to know why they need to know something; • Learn best through self-discovery with real and simulated experiences • Motivation is greatest when it is internal and when an activity presents new knowledge applicable to real life • Have an independent self-concept, take responsibility for their lives, are self-directed, and have a deep need to control learning.

16. Experiential Learning Principles • Significant learning takes place when the subject matter is relevant to the personal interests of the student • Learning which is threatening to the self (e.g., new attitudes or perspectives) is more easily assimilated when external threats are minimized • Learning proceeds faster when the threat to the self is low; • Self-initiated learning is the most lasting andpervasive.

17. Cognitive Learning Principles • Learning activities must provide multiplerepresentations of content • Instructional materials should avoid oversimplifying the content domain and support context-dependent knowledge • Instruction should be case-based and emphasizeknowledge construction, not transmission ofinformation • Knowledge should be highly interconnected rather than compartmentalized.

19. Assessment • Footprints (EMR documentation, mammograms, BRCA test ordering) • Knowledge (MCQs) • Attitudes (surveys, OSVEs, 360 evals) • Behaviors (OSCEs or SP visits) • Self Assessment*

20. Self Assessment: The Reality • Hundreds of articles • Many literature reviews • One conclusion: Self-assessment ability is generally poor

21. Three Key Patterns of Data • Little or no relationship between externally generated scores and self-assessed scoresAll but the very highest performers tend to overestimate abilityWorst offenders are in lowest quartile of performance

22. The Rhetoric of Self-Assessment • Adult education literature promotes expertise as a process of effective self-reflection • Lifelong, self-directed learners • The health professions have embraced a philosophy of professional autonomy and self-regulation • “Demands competent and trustworthy self-assessment by members”

23. Kruger & Dunning (1999) • “Unskilled and unaware” • The skills required to know whether you are performing well are also the skills required to actually perform well

24. eDoctoring

25. New DeliveryModels One Family Call One Meeting Personalized News Video Mails Employee Meeting Personalized Customer Meeting Commute Email / Voice Leisure Time Time Delayed Shows / Sports Intelligent Highways / Cars Physical / Virtual Health and Safety Monitoring Parents Update The New World: On The Human Network Connected Anywhere, Anytime, Any Device Students, Residents, Doctors, Adminstrators, Parents…

26. On Line Education • Doctors have little time • Interested in behavioral change not just knowledge • Best practice / poor practice • Safe environment where they can be engaged • Active involvement and self-managed learning

35. Assessment • What do doctors actually do with patients? • Prior data from PCa shows doctors report behaviors that patients report are not practiced • Data shows that doctors over-rate their engagement and interaction compared to patients

36. Is our program effective? Enhanced Patient Outcomes KnowledgeRetention Practice Improvement KnowledgeAcquisition

38. Catherine Douglas • Age: 41 • Gender: Female • Race: Caucasian • Education: Some college • Employment: real estate appraiser • Reason for visit: • “My sister was recently diagnosed with breast cancer. Although I am very concerned about her, I was wondering how much I have to worry about getting breast cancer myself?”

39. WHAT DO WE LOOK FOR? • Open ended questions? • Balance and framing • Use of simple, understandable language? • Checking on patient’s understanding? • Values clarification / shared decisions? • Factual accuracy / truthfulness • Medical topics (risks/benefits, confidentiality, cost, implications of a pos / neg result….)

41. Do people like CME Online? • Yes! • 98% would recommend to a colleague • Number one recommendation for how to improve: add more cases • Hundreds of quotes from satisfied participants • High ratings in evaluation surveys • Willing to pay for it!

42. Summary • Physician participation in online CME is increasing each year • Our program evaluations show knowledge acquisition, application of learning, and behavior change • More work is needed to assess patient outcomes • More work to be done with smart phone apps…

44. Analysis of the Learner • Who is your target audience? • Cognitive characteristics • Specific content knowledge • Prior experiences • Physiological characteristicsn Agen Sensory perceptionn General healthn Psychosocia characteristicsn Interestsn Motivationsn Attitude toward learningn Moral developmentn Job position and rankn Role Models • Gagne, R., Briggs, L. & Wager, W. (1992). Principles of Instructional Designv

45. confidentiality