Education and debate

10 Barnes B. About science. Oxford: Blackwell, 1985. 20 Coulter A, Peto V, Doll H. Patients’ preferences and general practitioners’
11 Cornwall A, Jewkes R. What is participatory research? Soc Sci Med decisions in the treatment of menstrual disorders. Family Pract
1995;41:1667-76. 1994;11:67-74.
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13 Irwin A. Citizen science: a study of people, expertise and sustainable development. Br J Gen Pract 1994;14:91-7.
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Continuing medical education

Learning and change: implications for continuing medical
education
Robert D Fox, Nancy L Bennett

This is the third Medical education, particularly continuing medical

in a series of education (CME), has been greatly influenced by Summary points
seven articles studies of adult learning. The observation that it is not
looking at teaching but learning that leads doctors to change
The purpose of continuing medical education is
international their practice has resulted in a shift in perspective:
to facilitate change in clinical practice
trends and rather than education being regarded as instruction, it
forces in is regarded as facilitation of learning. This paradigm CME should be based on the natural processes
doctors’ shift has been based on research into how and why learners use to change
continuing doctors change their practice and into the role of
professional learning in that process. Three interconnected systems are used in making
development The direction of continuing medical education in changes: self directed curriculums, small group
North America and elsewhere has changed in interaction, and organisational learning
Research Center for
response to the new perspective that has emerged
Continuing from contemporary studies of learning and change. CME must construct systems to complement and
Professional and The nature of this new perspective is evident from a
Higher Education,
support the learning of practice based learning
University of comparison of the common elements of CME in the
Oklahoma, 1980s with the approach that is now being used.
Norman, OK Traditionally a CME programme was an educational
73037-0003, USA
Robert D Fox,
event that applied appropriate resources and methods intervene in illness to change the health status of
professor to fulfill set instructional objectives. Such programmes patients, the aim of CME is to intervene in those
Department of were often considered to be good if the information aspects of medical practice that can be improved. CME
Continuing was valuable, the lecturer skilful, and the setting is a systematic attempt to facilitate change in doctors’
Education, Harvard comfortable. Too often, however, there was little or no
Medical School,
practice.
PO Box 825, actual effect on medical practice, even though all three Differences observed over time in patients’ health
Boston, MA 02115, conditions were met. and in doctors’ performance and their knowledge and
USA
The critical difference in the 1990s is that it has skills are the types of changes that have been the focus
Nancy L Bennett
increasingly been accepted that CME programmes are of research on CME. Change in one of these areas may
Correspondence to: based—or should be—on the principle of teaching and
Professor Fox
or may not lead to changes in another. For example, a
rfox@ou.edu education as a means of facilitating learning. This new change in the ability to perform a clinical procedure
Series editors: Hans
approach has been adopted in response to studies on does not always result in that procedure being
Asbjörn Holm and how and why doctors change their performance in incorporated into clinical practice. Furthermore, a
Tessa Richards clinical practice and the role of learning in that process. change in clinical performance does not automatically
This article describes some of these models and sets lead to a change in patients’ outcomes.
BMJ 1998;316:466–8
out the key principles that have emerged for These distinctions have challenged planners of
continuing medical education in the past decade. continuing medical education to identify their objec-
tives more clearly. What has emerged is an emphasis
on doctors’ performance as the target of strategies to
Understanding change in clinical
facilitate learning and change. This focus calls for
performance needs and outcomes that are described in terms of the
Understanding and managing change is an essential performance of doctors rather than their competence
part of professional practice. Just as doctors wish to or the health status of their patients.

466 BMJ VOLUME 316 7 FEBRUARY 1998

 Education and debate

Understanding the context of change

and learning Features of an innovation that modify its
adoption
Clinical practice is influenced by many factors. Doctors
who participated in a study of how and why doctors • Complexity of the innovation
change described a collection of forces as the reason • Relative advantage over existing practices and
they changed their practices.1 The forces emerged procedures
• Opportunity to observe the innovation in use before
from their personal lives, their professional aspirations,
adopting it into practice
and the social and cultural milieu of their practice set- • Compatibility with other similar products and
tings. They included curiosity, sense of personal and procedures already in the professional’s practice
financial wellbeing, stage of career, desire for new or • Opportunity to try the innovation before adopting it
enhanced competence, pressures from patients and
colleagues, and pressures from the healthcare institu-
tions in which they worked. x He or she also makes an estimate of what he or she
Different forces seemed to scatter doctors in differ- presently knows or is able to do in terms of the image
ent directions. Personal forces were associated with of change;
larger and more complex changes, professional and x The doctor estimates the discrepancy between what
social forces with smaller and simpler changes. Regula- he or she ought to know or do and what he or she cur-
tions were associated with only small accommodations, rently knows or does; and
which were usually made with resentment. x The doctor experiences a level of anxiety because
Once doctors note forces for change, they begin to what is known or done does not match what ought to be.
imagine what it would be like to perform differently in For example, a doctor considering prescribing a
the clinical setting and how the role of their staff may new drug for depression must imagine what he or she
change. The image of change varies according to what ought to know to manage the drug and its side effects.
forces are at work and what type of change is being Then the doctor estimates what he or she currently
pursued by the learner. Large or complicated changes knows about prescribing drugs for depression. This
are difficult to imagine; smaller simpler changes are “gap” between what is and what ought to be is an esti-
easier. Rogers describes five features (box) which affect mate of his or her learning need. The drive to reduce
the process by which professionals encounter and use anxiety associated with this need is the motivation to
new processes and products in their professional prac- learn and change.
tices.2 This model of need and motivation shows that
These ideas have been validated by a study on altering doctors’ perceptions of where they are, where
Canadian radiologists which found that these five fea- they believe they ought to be, and the size of the
tures are characteristic clues as to why different types of discrepancy can alter their perception of need and the
changes are pursued and how this happens.3 It also extent of their motivation to learn and change.
suggested that how the change is imagined affects its
adoption.
Understanding ways of learning
Understanding the role of needs and Research into the effects of continuing education on
doctors’ behaviour has fuelled further investigation
motivation
into how learning explains changes in practice. Two
Once doctors develop an image of change, they use different facets of practice based learning have
this image to estimate their personal need to make a emerged.
change and to seek new levels of competence related to
the image of change. This process of self assessment Self directed learning
involves four stages: The first model, referred to as the self directed curricu-
x The doctor estimates where he or she ought to be in lum, consists of three stages.4–6
terms of knowledge, skill, and performance related to x Stage 1—learning is directed toward understanding
the change; and estimating personal levels of need to learn in order
to adopt a change in practice
x Stage 2—energies are applied to learning the new
competencies needed to practise differently
x Stage 3—learning is organised around the problems
of using new skills, altering the practice environment,
or adapting the new way of practice to increase the
goodness of fit.
In each of the three stages, the learner identifies
and utilises resources drawn from three broad catego-
ries: human resources, especially colleagues and
coworkers; material resources, especially journals and
other sources of information; and formal continuing
education programmes, such as national specialty soci-
ety programmes. Because the selection and use of
resources is under the control of the learner, the “cur-
DAVID HITCH

riculum” is self directed—it is developed and managed

by the learner.

BMJ VOLUME 316 7 FEBRUARY 1998 467

Education and debate

Learners need to understand how they learn and

how their learning strategies may improve in order to Role of CME providers
become more efficient and effective. Educators need to
understand the natural patterns of doctors’ learning so • Facilitate self directed learning by providing for self
assessment, the acquisition of knowledge and skills,
that they can design learning programmes and experi-
and the opportunity to reflect on clinical performance
ences that complement self directed curriculums in a • Offer high quality individual and group education
profession where change and learning are routine and that provides authoritative information, knowledge,
necessary. and skills based on expertise and evidence
• Assist healthcare delivery systems to develop and
Organisational learning practise organisational learning
In self directed learning the focus is on the individual,
but doctors also learn from their work with patients, on
teams with other healthcare professionals, and in con-
sultation with colleagues. Within the culture of health and essential component is the self directed
care, each setting from primary care to tertiary referral curriculum designed by each doctor to incorporate
units represents a unique organisation with a new knowledge and make use of his or her own
personality shaped by beliefs, norms, and ways of experience.
thinking, learning, and adjusting behaviour to changes The second component is based on learning in
in the environment. groups. Ranging from journal clubs to formal,
Explanations of organisational learning point to traditional courses of instruction, these activities may
the potential power of adding together what each indi- be sponsored by organisations such as medical schools
vidual in an organisation knows in order to create and professional associations. Group learning serves as
some new way for the organisation to perform its func- a source of interaction and helps to shape the image of
tions.7 Understanding how knowledge grows in change and the practice of medicine. Lectures and
organisations, what fosters learning, and how organisa- other formal teaching activities have a long history.
tions make changes in response is fundamental to the They are both a creator of meaning and an artifact of
implementation of change. Senge asserts that organi- the culture of medicine. Lectures will endure because
sations can learn and that learning can be enhanced by they provide information on what ought to be and the
changes in organisational structure and climate.7 opportunity to reflect on what is being done, as well as
Structures can support evaluating experiences, trans- summarising evidence as to what can be done, to
forming them into knowledge relevant to an organisa- improve patient care.
tion’s core purpose and making them accessible to the The third component is learning within learning
whole organisation. Watkins and Marsick define a organisations. Hospitals, clinics, group practices,
learning organisation as one that provides continuous accreditation bodies, social service agencies, and
learning opportunities, supports collaboration within
governments reflect societal needs and demands in
the organisation, and fosters links between the
different ways. By gathering and processing infor-
organisation and other relevant organisations and
mation and feedback, learning organisations create
individuals outside the organisation to promote its
some of the standards that govern practice and modify
effectiveness and establish its place in society.8
others to fit the local problems and needs.9 They also
Health care has used ideas from studies of organi-
provide opportunities for doctors to learn how to
sational learning to develop systems to review and
adapt to these standards successfully.
change organisational behaviours. Practice review pro-
cedures, patient care audits, and quality assurance These three systems must be integrated in order to
reviews are examples of techniques that have become be effective in facilitating change and learning in
popular. Continuous quality improvement techniques, practice. Changes in health care, new research in
which are based on activities such as reviews of quality CME, and future demands must be brought together
of care, surveillance of infection control, case reviews, in new ways that will be powerful and sensitive enough
and measures of patients’ satisfaction, represent newer to respond to patients, practitioners, and healthcare
ways to shape organisational behaviours. All are systems.
intended to set standards that will ensure ongoing
changes in clinical practice. Informal activities such as
morning reports and rounds further support organisa-
tional learning by defining standards for behaviours 1 Fox RD, Mazmanian PE, Putnam RW, eds. Change and learning in the lives
appropriate to the culture. Healthcare organisations of physicians. New York: Praegar, 1989.
2 Rogers EM. Diffusion of innovations. 4th ed. New York: Free Press, 1995.
may also foster organisational learning by using 3 Rankin R, Fox R. The process of innovation adoption by Canadian radi-
outside resources. They may bring in a consultant to ologists. J Continuing Educ Health Professions1997;17:173-87.
assess the protocol for coronary artery bypass surgery, 4 Bennett NL, Casebeer LL. Evolution of planning in CME. J Continuing
Educ Health Professions 1995;15:70-9.
incorporate standards set by an outside organisation 5 Bennett NL, Fox RD. Challenges for continuing professional education.
for screening techniques, or collect population health In: Curry L, Wergin JF, eds. Educating professionals: responding to new expec-
tations for competence and accountability. San Francisco: Jossey Bass, 1993.
statistics to improve immunisation rates in children. 6 Fox RD, Davis DA, Wentz D. The case for research in continuing medical
education. In: Davis DA, Fox RD, eds. Physicians as learners. Chicago: AMA
Press, 1994.
Implications for the future of CME 7 Senge P. The fifth discipline. New York: Doubleday, 1990.
8 Watkins K, Marsick V. Sculpting the learning organization: lessons in the art
In the future, comprehensive CME systems will incor- and science of systematic change. San Francisco: Jossey Bass, 1993.
9 Confessore S. Building a learning organization: communities of practice,
porate what we know about learning and change into self directed learning and CME. J Continuing Educ Health Professions
three interlocking components. The first, most basic, 1997;17:5-11.

468 BMJ VOLUME 316 7 FEBRUARY 1998