Did You Get That? — Evolution
in Physician Learning
Thomas James III, MD
R
eturning to Philadelphia where I did
my residencies several decades ago has
dramatized for me the changes in physician education over time. Back in the prior
millennium, medical education was based on
the didactic principles handed down from Sir
William Osler’s time. The knowledge hierarchy was dictated by the length of the lab coat.
Learning was based upon textbooks, journal
clubs, and bedside experience. Dr. Gene Stead at Duke University
was well recognized for his belief in experiential learning, having
interns work 36 hours in the hospital and with only 12 hours off.
He worried that there would be no learning during that 12 hours
out of the hospital. Many of us were thankful for every-third night
schedules. But the concept was that through both a disciplined work
ethic and high exposure to hospital patients, for young physicians
would maximize the learning experience.
The concept of evidence-based medicine revolved around quoting
recent articles from prestigious medical journals. Guidelines were
considered “cookbook medicine” as the prevailing view of medicine
was that of an intricate and complex art.
More contemporarily trained physicians are more likely to have
access to facts, protocols and evidence-based medicine. Much of
the traditional lectures and presentations remain. Experience on
the hospital floor has been reduced as part of the efforts to reduce
fatigue-associated medical errors. While internet websites with high
quality professionally-oriented information are now used by doctors
across the age spectrum, it is the younger physicians who are more
likely to go to Wikipedia, YouTube or even Facebook for information
and professional information exchanges. Younger physicians mirror
their contemporaries with an 86% adoption of social media in the
18 to 29 year age cohort. It is clearly evident that younger physicians
in practice today are much more facile with internet learning, just
as older physicians felt comfort with learning in group discussions
while gathered around some poor sick patient. Medical education
is changing its venue and its processes.
The basic tenets of adult learning have to be considered since once
a physician leaves training, formal learning processes change. Dr.
Malcolm Knowles has indicated that such learning recognizes that
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LOUISVILLE MEDICINE
adults (including practicing physicians) bring experience to help
frame the new knowledge presented to them. Most adults learn from
task-oriented situations, so become ready to learn when the adult
feels it is important and relevant information.
Further, learning preferences involve the same domains of learning styles for physicians as they do for other adults. These domains
include preferences for visual, auditory or kinesthetic learning. Most
adults use a combination of these three styles but with individualized preferences. Additionally, work on adult learning shows that
intentional, spaced repetition of information increases retention by
50%. Studies show that we retain roughly 10% of visually presented
information, 30 to 40% of material heard via lecture or group discussion, and 90% of what is based upon experience supplemented
by visual and auditory information.
But there are barriers to the implementation of new learning into
the physician’s practice. The adoption of evidence-based medicine
(EBM) has been the most widely studied. In part this is also a reflection of the prevailing view in “Quality Circles” and in Washington
that health outcomes of the population will improve if physicians
just practiced more evidence-based medicine. So physician adoption
of HEDIS and NCQA measures (that demonstrate practical use of
EBM) makes a convenient and a politically correct area to study
physician learning and practice barriers.
Zwolsman et al performed a meta-analysis of the barriers experienced by primary care physicians in the UK and found that the
principal barriers to physician adoption of evidenced-based medicine
involved a number of issues:
•
Physician concern with the evidence: the doctor may q