Learning from email

One of the things that I want to explore on this blog are the techniques that have been particularly successful in medical education and CME. In 2007, a study was published in Medical Education, that I find particularly interesting (Medical Education, 2007, 41(1):23-31.)

The paper looked at the effect of "spaced education" which has been a consistently strong way to deliver education and training. Spaced education is simply education that's delivered over time. Instead of an hour of straight learning, you might have 10 minutes of learning once a day for six days. Spaced education is powerful, results of studies over may decades have shown that spaced education is more efficient, and it's more effective than "massed" learning. It's perfect for the tools we have available today, such as email and mobile technology.

The authors of the study used a pretty simple intervention. Third year medical students, in a one week urology rotation, were sent 10 - 13 emails with multiple choice questions or simple cases related to their urology learning objectives. . They got the emails over a period of up to 11 months. At the end of the academic year, they took a test on the content.

The students who had received the spaced education did significantly better on the test, and the strongest effects were up to 11 months after the intervention.

I like this study and its simple design - it used a powerful, and tested, learning technique and paired it with a ubiquitous tool (email), to get a strong outcome. I think we're likely to see more spaced educational interventions in the future.

Guidelines for CME

In developing CMEs, I've always tried to make sure that the program incorporates, or at least mentions, any relevant clinical practice guidelines. There are, afterall, the best collective wisdom that we've got. That's why I was excited to stumble onto the Evidence-Based Guidelines for CME recently published in a special supplement of Chest (Chest, 2009, 135, Supplement).

There's lots of information for developers of CME programs, and for those researching CME effectiveness. The Guidelines cover the effect of CME on knowledge, practice performance, clinical outcomes, and include a discussion on audience characteristics and external factors in CME, and the use and effectiveness of simulations.

What Works to Change Practice

What can we do to help physicians improve their practice? There is research that can help guide decisions and priorities. In a 1998 “review of reviews,” looks at methods that have improved practice. The educational message is pretty clear – didactic methods will not work, we need to include education that that helps physicians think about, and practice their new knowledge.




Consistently Effective Interventions

Reminders (manual or computerized)

Multifaceted interventions

Interactive educational meetings that include at least include discussion or practice



Interventions of Variable Effectiveness

Audit and feedback

Local opinion leaders

Local consensus processes

Patient mediated interventions



Interventions with little or no effect

Educational materials, including clinical practice guidelines, recommendations for clinical care, audiovisual materials, and electronic publications

Didactic educational meetings





Bero, L.A., Grilli,R., Grimshaw,J.R., Harvey, E., Oxman, A.D., and M Thomson (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ; 317 : 465.

CME in Second Life

There was a big surge in interest in virtual reality as a training tool about five years ago when Second Life, and several other virtual reality tools became widely available.  Much of that initial excitement has died down.  I suspect that there are a number of reasons that it has faded but one reason may be that many people did not use the technology very well.  I went to a number of presentations in Second Life, but most were merely lectures, which can get boring, no matter what the technology. 

Lectures aren't the only things that you can do in Second Life though.  I think that one very promising use of the technology might be for training that involves role playing. Virtual reality offers some potential advantages over face-to-face role playing - including alleviating a little of the embarrassment that people can feel when they're the center-of-attention. 

Two recent blog posts (first, second) by Robin Heyden describe the experience of delivering continuing medical education on motivational interviewing to family physicians.  The training included a 40 minute presentation on motivational interviewing, followed by practice sessions. 

There are lots of caveats, including the usual problems that new user often have accessing all of the media in Second Life, but overall, it's a very interesting step and one that I'll be paying attention on the future. 

Here is the presentation portion of the training:

CME can alleviate misconceptions about back pain

A recent paper in Spine (2009, 34(11), 1218-1226) looked at general practitioner knowledge about back pain treatments. 

Doctors who had recently participated in CMEs about lower back pain had significantly better pain management beliefs, supporting the importance of CME for updating people’s knowledge. 

One surprising result was that physicians who self-identified as having a special interest in lower back pain were actually less likely to understand the most appropriate treatments, which include continued activity, rather than bed-rest.   That’s right, physicians in this survey, with an interest in lower back pain, actually knew less about how to treat it.  This may be a statistical hiccup, but it might also fit with the idea that people are actually very poor at self-evaluating their own knowledge and skills (see, for instance Advances in Health Sciences Education, 2004, 9(3):211-24). 

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.