It’s about the thinking skills, not the information

A recent TED Talk by Diana Laufenberg, a social studies teacher, makes an important point about what, and how, students need to learn. She teaches younger students but I think her ideas hold for adult students as well. 

They don’t need experts for information anymore, information is all around them.  What they need are to develop thinking skills.  Laufenberg’s grandmother needed to listen to her teachers to get information.  Laufenberg grew up with the advantage of encyclopedias as an additional information source.  Her students have huge amounts of information literally at their fingertips. 

They don’t need a teacher to tell them facts, they need a teacher to help them develop skills to use the information already available to them.

Coaching and Practice Improvement

Does learning lead to practice improvement?  I have done some learning research, and I used to think that learning was the really important thing.  If we carefully designed our instruction to maximize learning, that meant that people would be able to use that knowledge to in their work. 

Experience and a much broader view of the learning literature though, has taught me that improving people’s work performance is not always simply about learning.  Sometimes, helping people perform better at work is like helping them change their behavior.  And behavior change is hard.  Smokers all know that they’d be better off quitting, and we all know that losing weight is as easy as exercising a little more and eating a little less.  It’s actually using that information and knowledge that’s the hard part. 

Recently, I've been thinking of performance improvement a little more like behavior change.  It often takes more than just a learning session or two to make an improvement and there may be times when people need a lot more than just learning a new skill.  They may need a little more help and coaching to use their new skills in their jobs.  

A recent paper (JAMA, 2010;304(15):1693-1700) discussing the adoption of surgical safety procedures shows the effect of coaching after the learning intervention.  The surgical teams learned to use new safety techniques by a three step process – planning for the change at the facility, a one-day training where the teams got a chance to practice their new skills, and follow-up coaching by phone.  The intervention was successful. 

The interesting thing was the effect of the coaching.  Teams that got more coaching had had better scores on safety measures in a clear dose-response effect:

Of interest is the dose-response relationship between the number of quarters the training program had been implemented and the rate of surgical mortality. As facilities implemented longer, their rate of surgical mortality decreased further. This suggests that it is critical not only to provide training but also to ensure that the tools are fully integrated into the surgical service. The year-long follow-up was helpful in ensuring that OR clinicians adopted the training tools and changed practice patterns.

Improving performance may sometimes involve more than just teaching people new skills, you may need to help them adopt those new skills as well. 

Informational Videos

Short videos can be a great way to get information across.  Videos don't have to be overly produced to be effective, oftentimes, simplicity and a clear message are the most important things. 

I am a big fan of the videos made by Common Craft.  Common Craft makes 3 minute explanatory videos that are very good example of the effectiveness of clean, simple, but very carefully designed messages.  Their approach is so basic in fact, that at first, it almost seems like a joke or a gimmick.  Watch a few though, and you can't help but be impressed.  My favorites are about insurance, passwords, social media, and Twitter. 

They follow some consistent design rules:

1. Each picture has a purpose.  Each picture has been carefully selected to communicate a clear message.  There are no decorative pictures or anything else to distract from the message.  Designers sometimes like decorations and decorative pictures, but studies have shown that they can decrease learning. 
2. The videos have useful metaphors that are used throughout.  The insurance video uses a life preserver metaphor.  It would have been easy to use the metaphor once and expect the user understand. Much better though, to use it throughout the video so that it becomes reinforced as a powerful, and simple symbol. 
3. The people are about as generic as they can be.  They often don't have faces, or distinguishable genders but it turns out that they don't need to. 
4. They're short.  Three minutes might not seem like a lot of time to explain a complex topic, but it can work. 

VA's new Simulation Research Center has a Good Overview Available

Simulation has been a valuable educational tool for decades in health care.  They have been particularly good for learning procedures and for specialties like surgery.  There has been an increasing interest in simulations and there should be many interesting studies of learning from simulations in the next several years. 

The Department of Veterans Affairs has recently opened a new Simulation Simulation Learning and Research Network (SimLearn).  They've already produced a great 124 page resource:  A Review of Simulation-Based Strategies for Healthcare, Education, and Training.  It's a good place to start for anyone wanting an overview simulations in health care. 

E-learning CME that changed practice behavior

One of the things I want to focus on in this blog are the kind of learning interventions that have been successful in changing practice behavior.    Today I'm looking at a study published in JAMA in 2005. 

In this study, what worked was 1) getting the information from an expert, 2) the opportunity to practice skills while working through cases, 3) the opportunity to spread the instruction out over a period of time, and 4) job aids that the physicians could use in their practices. 

This was a well-designed study comparing a previously successful live CME event for physicians, with the same material presented in an e-learning format, and a control group that did not receive instruction.  This was a good study, they measured learning immediately and at 12 weeks and more importantly, they measured actual physician behavior using chart reviews. 

The live CME consisted of a lecture, followed by interactive case discussion with faculty, the participants received a number of job aids to help them when they got back to work. 

The internet based instruction was designed to give people a similar experience - a recorded lecture, followed by cases that the physicians could work through.  Both sets of learners had access to faculty if they wanted to ask questions.  the internet CME group also had a live session, where they worked through cases with an expert. The major difference was that the internet-based instruction was done at the learners' convenience, and often over several different sessions. 

Learning increased for both the live and the internet-based instruction group, both immediately after the instruction and at 12 weeks. 

Practice behavior only changed significantly for the group that received instruction over the internet. 

This is kind of a surprising result, why should the internet-based instruction be successful, while the live-training was not. 

One reason might be that the internet-based group had the chance to complete the instruction in a single sitting.  This fits with the instructional principle pf spaced practice - that is - spreading the practice over a period of time, which gives people a better chance to learn the material. 

Cognitive Design for Online Medical Education

Richard Mayer has written a new article in Medical Education about applying the fundamentals of cognitive design to multimedia or online medical education.  We know a lot about how to structure instruction to help people learn and Mayer's article is a very good introduction for people interested in learning more about how to do it.  Mayer's writing has influence a lot of good multimedia design and his recommendations are all based on careful research. 

Principles for instructional design include reducing the amount of extraneous cognitive processing (that is, processing that isn't related to the learning task), principles for managing essential processing (that is, processing that is related to the learning task), and principles for fostering generative processing. 

These principles are probably best used for relative novices, or for an introduction to a subject but understanding these principles can help you develop online learning and even PowerPoint presentations.

DevLearn 2010

I've just come back from DevLearn 2010, the biggest e-learning conference in the United States.  The conference was packed with many interesting people and ideas. 

There was a lot of talk about social learning.  I've become increasingly convinced over the last several years that social media can be an important tool for learning in health sciences professional education. 

I have several new books to read including the "Working Smarter Fieldbook" by the folks at the Internet Time Alliance.  The book is filled with good information that will take some time to digest.  I'm also getting ready to read Tony Bingham and Marcia Conner's book, "New Social Learning". 

Redesigning Continuing Education in the Health Professions

A recent report from the Institute of Medicine (IOM) suggested several ways to improve continuing education in the health professions.  The recommendations in the report would greatly improve the continuing education, especially for educational programs for teams of providers from different disciplines. 

Some of the problems with the current system identified in the report:

• a lack of scientific understanding of what kinds of training are effective
• fragmented oversight of continuing education

Lack of Scientific Understanding of Effective Training
One of the things I'm interested in, and the reason I'm writing this blog, is to explore the science of learning and to look at how that has been, and can be applied to continuing education in the health professions.  We know a lot about how professionals learn, but there is much more that we need to understand. 

Fragmented Oversight of Continuing Education
Each discipline (doctors, nurses, social workers, psychologists, etc) has their own accreditation body and their own set of rules to follow.  This isn't a problem if you're planning learning for only one group of professionals.  More and more though, it's becoming apparent that teams of professionals who work together with specific patient populations, should be trained together.  It can be a struggle to create an accredited learning experience, that meets the requirements for each of the separate groups, especially if you're trying to do something that is slightly unconventional. 

Internet-Based Learning is Just as Effective as Face-to-Face

If distance learning is well-conceived and carried out, there are no differences in learning based on studies comparing live training to internet-based training. 

This is the major finding of a review published in JAMA in Sept. 2008 titled, Internet Learning in the Health Professions: A Meta-analysis.  This paper was written by the research group of Cook, Levinson, Garside, Dupras, Erwin, and Montori, who have been writing a lot of very interesting papers on learning from technology in the health sciences. 

They looked at 201 studies, some comparing internet-based learning with a no intervention group and comparing internet-based learning with a face-to-face alternative.  They looked at three different outcomes: knowledge, skills, and behavior/ effects on patients. 

What did they find?  That internet-based training was no different than live training.  Their findings are similar to publications from other fields showing that at worst, there is no difference between learning online and face-to-face learning. 

The conclusion:
It's a waste of time to continue doing studies comparing internet learning with face-to-face learning, it's time to start looking at exactly what kinds of activities and instructional methods lead to better learning. 

In future posts, I'll look at some of the things that you can do to improve learning and outcomes for your online learners.  

Expertise

Over the last 25 years, there has been a lot of research on how people develop expertise.  Our understanding of what expertise is, and how people develop it, has increased greatly.  One of the leading thinkers on expertise has been K. Anders Ericsson.  This literature is important because it can help us understand how to set up the conditions that can support expert performance within an organization, as well as helping us figure out ways to develop our own expertise. 

Ericsson and colleagues wrote a paper for the Harvard Business Review that is a very good introduction to expertise: The Making of an Expert. 

Among the highlights:

Consistently and overwhelmingly, the evidence shoes that experts are always made and not born.  We often think that people have inherent skills and abilities but this just doesn't turn out to be true.  Expertise is developed.  Developing expertise in a subject takes hard work.  In fact, the most important factor in studies of expertise are quality practice time – not inherent factors like IQ, learning styles, or anything else.  This has been shown to be true for every field that’s been studied.  The only exception is in sports where body size and height are important.

It takes time to become an expert – most people need a minimum of ten years of intense training.  Ten years of simply repeating the same things over and over again will give you experience, but it won’t make you and expert.  Expertise takes a constant drive to improve your own performance.  This means focusing on the things that you things you need to improve on, not on the things you can already do well. 

Practice must be deliberate.  Real experts seek out constructive (and sometime even painful) feedback.  The best way to improve is to constantly get, and act on, feedback about your performance.

Understanding expertise is important for anyone designing professional education experiences because we want to make sure that we're supporting the development of expertise.

For a more in-depth look at expertise (including a chapter on expertise in medicine), check out the The Cambridge Handbook of Expertise and Expert Performance. 

How to use video

Providers in a trauma center aren't using sterile technique and they need training.  What kind of training are they likely to get?  Pamphlets?  Presentations by highly regarded or experienced providers?  Maybe if there's enough money in the budget, they'll get training that incorporates video.  One thing we know is that the training will likely be more successful if it involves some kind of interaction because training that uses passive methods is not likely to lead to any changes in behavior. 

A group from the University of Maryland used video in their training, and they did it in very interesting way.  Instructional videos often use an expert, doing the procedure perfectly.  The idea is that people will see this and be able to copy the perfect performance.  The problem is though, that it's possible to watch videos like this, and not process any of the information being shown. 

The Maryland group did a very clever thing: they used videos of providers doing the procedure, using common non-compliant behaviors.  Then, instead of passively watching, they had the trainees watch for mistakes during the filmed procedures.  This kept them thinking about, and processing the information.  The result was a significant increase in sterile procedures in the group that watched the videos. 

The bottom line?  Training that asked learners to evaluate real situations had a significant effect on sterile procedures.  If you're going to use video in your training, try to use it in a way that helps people think about what they're doing. 

Lectures don't work

Lectures are usually a pretty bad way to help professionals learn something.  In fact, most of the evidence points to the fact that for professional continuing education, they don't really have much of an effect at all on either learning or on subsequent changes in practice that we often expect from CME programs. 

If you want to find out more about what has worked, and what hasn't worked in CME programs, The best single reference I've found is this JAMA review paper from about 10 years ago, I consider it a must-read for anyone involved in CME.  The authors looked at published studies of CME activities and the measured outcomes.  It's a very good read, but the bottom line is simply this - didactic instruction does not change physician behavior.  What does change physician practice behavior?  Giving people the chance to practice their skills and get feedback is one of the methods that seemed to work the best.   

Having professionals sit and listen to a presentations isn't always a negative.  If you want to give people information about a topic, or give them a broad overview, didactic instruction isn't necessarily a bad way to do it.  Where lectures don't work though, is when you want people to develop, or use, complex knowledge or skills.  This is pretty well accepted by most people in education but it doesn't seem to be widely known by others. 

Cognitive Difference

Medical professionals like doctors, nurses, social workers, therapists and others need education and training to help them stay up to date.  How do we help professionals learn the new skills they need to keep improving?  I plan to use this blog to explore some of the things that do seem to work.