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Applying Adult Learning Principles. Society for Academic CME April, 2003 Santa Fe, New Mexico Joseph S. Green. Operational Functions Certifying activities Designing, implementing and evaluating activities Documenting credit for physicians. Academic CME Functions

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applying adult learning principles

Applying Adult Learning Principles

Society for Academic CME

April, 2003

Santa Fe, New Mexico

Joseph S. Green

medical school cme
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
current status
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.
survey of sacme
Survey of SACME

% of time spent on Academic CME

  • 0- 25%
  • 26%-50%
  • 51%-75%
  • 76%-100%
survey of sacme5
Survey of SACME

If 0-25%,

  • 0-10%
  • 11-15%
  • 16-25%
one example of academic cme activity
One Example of Academic CME Activity:

Applying Adult Learning Principles to Undergraduate Medical School Curriculum: Working Across the Continuum to Enhance Physician Competence

does your medical school cme office contribute to the continuum of medical education
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
why is there a need to collaborate across the continuum of medical education
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
characteristics of adult learners

Characteristics of Adult Learners

Duke School of Medicine

Curriculum Revision Project

Joseph S. Green, Ph.D.

Associate Dean, CME

January, 2002

the setting
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’
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)
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
the new vision for clinician life long learning and cme

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

forces in health care pushing accountability
Forces in Health Care Pushing Accountability
  • Evidence-based care
  • Intolerance of variation
  • Demanding customers
  • The information revolution
  • Systems awareness
two landmark iom reports
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
physician education
Physician Education
  • Medical School (UGME)
  • Residency (GME)
  • Life-long (CME)
maintenance of certification
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

evidence of lifelong learning
Evidence of Lifelong Learning
  • “Certified” CME--some specialty specific
  • Self-assessment examinations
  • Participation in quality improvement
  • Self-directed learning
  • Documentation of competence
competencies expected throughout physician s career
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

next paradigm shift medical education
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
goal of curriculum revision project
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...

descriptors of your early education as a child
Descriptors of Your Early Education as a Child

How would you characterize it??

theoretical foundations
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
theoretical foundations26





Fluid Crystal

85% 15%

62% 38%

40% 60%

25% 75%

Theoretical Foundations
ten characteristics of adult learners
Ten Characteristics of Adult Learners

Acronym to remember them:



k link new k nowledge to previous experience
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
u need to u nderstand what they don t know and have a clear vision of what should be achieved
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
d d esire involvement in the learning process
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
learning by doing
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

e seek e nvironment that encourages critical self reflection peer collective inquiry
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
s have moved self concept from dependence to s elf directedness in the pursuit of knowledge
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…
medical model
Medical Model

History & Physical



Implement Rx

Treatment Plan

professional educational model
Professional Educational Model

Needs Assessment





curriculum design process
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
u u ndertake mechanisms for obtaining feedback on performance and reinforcement of learning
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
l have an innate ability to l isten l earn and remember
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
d process information through multiple sensory channels with d ifferent cognitive styles
DProcess information through multiple sensory channels with Different cognitive styles
  • Styles related to senses: auditory, tactile, visual
  • Learning style inventories (LSI)
a address practical problems with useful and immediate a pplications
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
t need skills to learn outside of structured t eacher centered settings
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
multi stage physician change process rogers 1983
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
curriculum implications
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
curriculum implications con t
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




How could you use this information to assist in your collaborating across the continuum of medical education?
a resource
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:

barriers to academic cme
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
cme vision for academic cme functions
CME Vision for Academic CME Functions
  • Vision of what could be or should be have existed for years/decades
  • Many Medical School CME Offices are initiating some isolated Academic CME activities
  • To increase our importance and usefulness within our institutions we must move beyond Operational Functions
cme vision for academic cme functions52
CME Vision for Academic CME Functions
  • As with facilitating the change in physician performance, we need to better understand why we have not been able to change our CME organizations
  • PROPOSAL: SACME considers undertaking a systematic study of the barriers to our change, documents ‘best practices’ and develops coordinated strategies for 3-5 year plan for improvement...