Lifelong Learning In Otolaryngology

Otolaryngol Clin N Am 40 (2007) 1323–1330

Lifelong Learning in Otolaryngology: Self-Directed Learning John M. Schweinfurth, MD Department of Otolaryngology and Communicative Sciences, 2500 North State Street, Jackson, MS 39216, USA

Professors are fond of telling graduates, ‘‘This is just the beginning of your education, not the end.’’ Nothing in didactic form approaches the learning experience of the real world, in which there are no textbooks, no lesson plans, and no teacher to fall back on. Many early decisions are based on a teacher’s transplanted wisdom. Often the transition is abrupt; the educational process up to graduation is based on a teacher-directed model of learning, for which there is no direct continuity in practice. Currently, there are multiple, instructor-led resources for long-term learning, including opportunities for continuing medical education (CME) from annual national and regional professional meetings, home study courses, audio digests, and online reviews. This article, however, is not about formal, teacher-directed learning activities, such as lectures and CME. The reality is that instructor-led CME activity, although valuable, represents not only an artificial learning environment but also a relatively ineffective one at that [1]. Active engagement in self-planned learning activities tends to be more effective than passive learning, which commonly characterizes formal CME. Most lifelong learning is problem specific and occurs in the context of real experience: the clinic, on an Internet search engine at night, or over the phone with a colleaguedthose conversations that invariably begin, ‘‘I got this guy..’’ Lifelong learning involves finding and implementing solutions to everyday problems encountered in the clinic, emergency room, and operating room and on the wards. The process by which much of this education occurs is via self-directed learning (SDL). According to Gibbons [2], a paradigm shift in instruction is ‘‘teaching students to challenge themselves to pursue activities that arise from their own experiences, employing their own emerging styles to find patterns of meaning and processes of productivity that lead E-mail address: [email protected] 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.07.011

oto.theclinics.com

1324

SCHWEINFURTH

them to a high level of achievement and fulfillment. The prime imperative.is not to enhance teacher-directed learning, but to develop a more studentdirected model.’’

What is self-directed learning? Hammond and Collins [3] describe SDL as ‘‘a process in which learners take the initiative, with the support and collaboration of others. For increasing self- and social awareness; critically analyzing and reflecting on their situations; diagnosing their learning needs with specific reference to competencies they have helped identify; formulating socially and personally relevant learning goals; identifying human and material resources for learning; choosing and implementing appropriate learning strategies; and reflecting on and evaluating their learning.’’ This humanistic characterization of SDL implies a sense of social awareness and responsibility, self-actualization, and the acceptance of personal responsibility for one’s own learning. The acquisition of SDL is a complex process that involves numerous skills and competencies relied on to complete challenges, such as medical school and residency. Unlike the classroom setting, in which the emphasis is on mastery of content, SDL emphasizes personal action taken to become more productive. Testing is no longer an issue, but performance certainly is. Many authors have identified SDL as essential to continuing education efforts in adults [4,5]. Not everyone is ready to accomplish SDL, however, because certain traits are essential for becoming a successful, productive person. Candy [6] synthesized an essential character list from more than 100 such traits (Box 1). Generally, SDL is not limited to specific settings but can occur as a part of any process and include formal learning activities. Among Tough’s [7] factors are three common patterns in independent study: (1) a specified learning need, (2) curiosity, and (3) general desire to learn. Houle [8] described three groups of adult learners: (1) goal oriented, (2) activity oriented, and (3) learning oriented. Of these types, many practicing physicians clearly fall into the first category, because they frequently embark on a learning project to acquire new procedural skills or become familiar with new medications or updates in coding and reimbursement schedules, for example.

The challenge model of self-directed learning Possibly the most influential essay on SDL is ‘‘The Walkabout’’ by Maurice Gibbons, which was published in the 1974 edition of the Phi Delta Kappan [9]. At the heart of the essay is the story of two children lost in the desert wilderness of the Australian outback. Facing certain death, the two are found and cared for by a young aborigine on his walkabout, a 6-month endurance test during which he must survive alone in the wilderness and

LIFELONG LEARNING IN OTOLARYNGOLOGY

1325

Box 1. Skills and competencies of the lifelong learner            

Being methodical and disciplined Being logical and analytical Being reflective and self-aware Demonstrating curiosity, openness, and motivation Being flexible Being interdependent and interpersonally competent Being persistent and responsible Being venturesome and creative Showing confidence and having a positive self-concept Being independent and self-sufficient Having developed information-seeking and retrieval skills Having developed knowledge aboutdand skill atdlearning generally  Developing and using defensible criteria for evaluating learning return to his tribe an adult. Gibbons surveys the ramifications of the story from a societal standpoint: ‘‘The movie is a haunting comment on education. What I find most provocative is the stark contrast between the aborigine’s walkabout experience and the test of adolescent’s readiness for adulthood in our own society. The young native faces a severe but extremely appropriate trial, one in which he must demonstrate the knowledge and skills necessary to make him a contributor to the tribe rather than a drain on its meager resources. By contrast, the young North American is faced with written examinations that test skills very far removed from the actual experience he will have in real life. He solves familiar theoretical problems; he does not apply what he knows in strange but real situations. His preparation is primarily for the mastery of content and skills in the disciplines and has little to do with reaching maturity, achieving adulthood, or developing fully as a person [9].’’

The walkabout model is applicable to the learning required by the practicing physician. First, it should be experiential and the experience should be ‘‘hands on.’’ Second, it should be a challenge that extends the capacities of the learner. Third, it should be a challenge specific to ordeven betterddesigned by the learner. A productive learning experience depends on the learner’s ability to make appropriate choices, but in most teacher-directed situations the student is not called on to make any meaningful choices. ‘‘The test of the walkabout, and of life, is not what (the learner) can do under a teacher’s direction, but what the teacher has enabled him to decide and to do on his own [9].’’ Most importantly, the trial should be an important learning experience in itself and should involve not only the demonstration of the student’s knowledge and skill but also self-awareness, flexibility, and personal nature.

1326

SCHWEINFURTH

The ‘‘change’’ model Fox and colleagues [10] developed a model of learning and change based on 700 incidents involving more than 300 physicians. The authors found that the most common forces for change were professional: a general desire for competence or the perception of a changing clinical environment. Once a need for change is identified, the physician develops an image of how the practice would appear after the change. Information is gathered to help analyze the gap between existing skills and skills necessary to complete the change. It is the process of analyzing and describing the gap that provides the jumping-off point for planning, developing, implementing, and assessing learning activities. The process of change involves three stages: preparing to change, making the change, and sustaining the change [11].

Learning through experience The process of learning through experience has been described in Kolb’s [12] experiential learning cycle. 1. Concrete experience: In the first stage, a physician may encounter an unexpected situation that differs from expected practice (eg, a complaint of hoarseness with a normal appearing larynx). 2. Reflective observation: After the encounter, the physician reflects on the experience, performs an Internet search, consults with a colleague, or perhaps takes no further action. 3. Abstract conceptualization: The physician combines the results of reflection with any new knowledge gained to conceive of a possible new approach that would theoretically encompass the problem (in this case, a neurologic disorder such as spasmodic dysphonia or vocal scarring). 4. Active experimentation: A new approach may be taken. In this example, a videostroboscopy might be performed or a new diagnosis considered and tested. The experience with the new approach (eg, findings on videostroboscopy) immediately leads to a new concrete experience and the cycle begins anew. Kolb’s cycle provides an excellent model for conceptualizing the learning process a practitioner might undergo as a result of clinical challenges encountered on a regular basis. An abundance of adult learning research supports the role of experience and reflection in continuing education [13–17]. In reality, the process is likely to be more dynamic, complex, and interrupted with fits and starts, dead-ends, misinterpreted experiences, and incorrect conclusions. An awareness of the process assists the learner and educator in designing and promoting educational experiences that allow for each stage to occur and mature.

LIFELONG LEARNING IN OTOLARYNGOLOGY

1327

Promoting self-directed learning Although internal motivation for learning is more powerful and enduring than external forces, near-term goals (eg, recertification and renewal of medical licenses and hospital privileges) are the order of the day when time is limited, as is always the case. Factors that may facilitate and combine these processes ultimately are more productive and satisfying to the learners and professional boards and licensing bodies. Specialty literature, national and regional conferences, and other CME activities may help learners identify gaps between needed skills and current capabilities and help learners to visualize an image of change to see how it might look to do something differently. Computerized learning modules and portfolio projects may potentially bridge these knowledge gaps. Similar to a teacher-directed learning experience, computer modules may serve to drive Kolb’s learning cycle by providing prompts and asking questions that require reflection or application of new knowledge. Online searches offer access to specific sources of knowledge not readily available in texts. Portfolio projects can serve to document the SDL processdfor refinement and potentially for CME credit or recertification. Identifying needs Physicians respond to areas of deficient knowledge by referring complex patients, having discussions with colleagues, and consulting the literature [13]. These behaviors are typically stimulated by perceived deficiencies from caring for a particular patient, having discussions, or reading. These deficiencies, however, are often subjective and may not accurately reflect actual needs. Objective needs assessment is needed to provide a more realistic image of knowledge gaps. Systematic assessments, such as performance audits and outcomes measures, patient care benchmarks, billing and documentation audits, are examples of objective measures. Other examples include independently reviewed portfolio projects and written or computerized tests and problem-based scenarios. Regardless of the assessment strategy used, it is important to allow the physician to develop a self-monitoring strategy rather than merely respond to external events. Computerized self-directed learning modules Adult learning theory, including Kolb’s cycle and the principles of SDL, depends on the developments of practical tools that help individuals take charge of their learning and apply the theory to their own practice. As personal computers and the Internet have enjoyed growing widespread use among physicians as essential resources, the potential for their application in CME also has expanded. Although the full potential of computerized SDL has not yet been reached, several models are available.

1328

SCHWEINFURTH

The maintenance of competence program is designed to encourage specialists to take charge of their own CME efforts [18]. The program has three components: (1) A credit system to promote production of high quality, practice-based, educational programs. (2) A self-directed CME plan designed to motivate individual specialists to record and critically appraise their CME activities. (3) An annual, personalized CME profile. Physicians obtain information in many ways (eg, reading, consultations, rounds, research), but these activities are too numerous to record on a regular basis and rarely lead to a change in practice. This information screening is defined as ‘‘general professional activity’’ in the revised maintenance of competence program and consists of scanning the professional environment for new ideas. Occasionally information does capture the interest of the specialist, who might then explore the area in more detail, which is known as ‘‘in-depth review.’’ These activities are focused and goal oriented and should lead to one of the following outcomes after completion [19]: (1) I will modify my practice. (2) I will wait for further information before I modify my practice. (3) I see no need to modify my practice. The computerized evaluative learning tool is based on the adult learning principles that learning should acknowledge prior experience, allow reflection, be participative, provide ownership, and be self-directed [20]. Users enter data under four menus, depending on whether they have a specific learning need, wish to apply new knowledge or learn from an event to reduce future risk, or wish to analyze and learn from the emotions the event caused. The four menus are as follows: 1. Educational need: The user starts with a learning need and the program takes him or her through meeting the need and then applying the learning in practice. 2. Educational event: The user recollects a specific learning point and is guided to apply it in practice. 3. Emotional response: This recollection allows learning from an emotional experience to take place and enables a change in future behavior. 4. Significant event analysis: This process allows learning to take place after a significant event in the workplace and enables the user to make changes to minimize the risk of a subsequent event. The computerized evaluative learning tool provides a learning structure to enable physicians to recognize and document that learning has taken place, be specific about what has been learned through reflection, and then, if appropriate, act on the learning and apply it in practice. Portfolio projects as a model for future recertification The computer models described previously provide not only a framework for SDL but also documentation of the process. This process and the accompanying documentation could potentially be used not only for CME credits

LIFELONG LEARNING IN OTOLARYNGOLOGY

1329

but also for recertification itself. The Royal College of Physicians and Surgeons of Canada and several of the specialty societies, including the Canadian Anesthetists’ Society, have developed the maintenance of competence program project as part of the recertification process. The philosophy of the maintenance of competence program is to develop a comprehensive CME strategy that will motivate specialists to update their clinical practice continuously. Whether through the use of a software-based SDL computer module or simply documentation on the computer, the use of portfolio projects as part of the recertification process benefits physicians in several ways. First, it encourages and formalizes the process of SDL. It is likely that the documentation will encourage an increase in quality of the process and product and the learning experience. Second, it encourages familiarity and skill with the process so that each time SDL is initiated with less reservation. Finally, and most importantly, the physician can be rewarded with specialty CME hours or potentially with partial recertification credit, depending on acceptance from accreditation bodies. Introduction of self-directed learning in the undergraduate curriculum The origins of Kolb’s work may be traced back to a famous dictum of Confucius circa 450 BC: ‘‘Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand [21].’’ As discussed at the beginning of the article, the transition from teacher-led to learner-directed activity is unnecessarily abrupt. Given the rapid changes in medical knowledge and practice, the need to keep abreast of the field is the one constant. But are graduates really ready for SDL? Kell and Van Deursen [22] identified a preference toward teacher-directed learning in average age learners and student-directed learning in mature learners. The differences in learning preference persisted 6 months after graduation. The results suggested that mature students enter the course with skills that equip them to be more flexible in their learning, less dependent on instructor direction, and more self-reliant. Although further research is needed to identify which life skills are practiced by mature students and those that would promote SDL if encouraged in younger students, activities that promote involvement and active learning, as discussed in (article titled ‘‘Interactive Instruction in Otolaryngology Education’’, elsewhere in this issue) would be expected to promote SDL in later life. Summary This article is intended as a primer and not a comprehensive discourse on SDL and its role in CME. It is every teacher’s responsibility to realize the impact of his or her teaching on learners so that the learners’ natural tendency for self-direction, displayed in their personal lives, can be transferred to their educational and working environments [23]. Similarly, national

1330

SCHWEINFURTH

specialty boards and associations, licensing boards, and governing bodies should recognize the importance of continuous SDL motivated by an internal desire to improve rather than merely a reaction to external mandates. References [1] Wentz DK. Continuous medical education at a crossroads. JAMA 1990;264:2425–6. [2] Gibbons M. Pardon me, didn’t I just hear a paradigm shift? The Phi Delta Kappan 2004; 85(6):461–7. [3] Hammond M, Collins R. SDL: critical practice. New York: Nichols/GP Publishing; 1991. [4] Fox RD, Bennett NL. Continuing medical education: learning and change. Implications for continuing medical education. BMJ 1998;316:466–8. [5] Towle A. Continuing medical education: changes in health care and continuing medical education for the 21st century. BMJ 1998;316:301–4. [6] Candy PC. Self-direction in life-long learning. San Francisco (CA): Jossey-Bass Publishers; 1991. [7] Tough A. Why adults learn: a study of the major reasons for beginning and continuing a learning project. Monographs in adult education. Toronto: Ontario Institute for Studies in Education; 1968. [8] Houle CO. The inquiring mind. Madison (WI): University of Wisconsin Press; 1961. [9] Gibbons M. Walkabout: Searching for the right passage from childhood and school. Phi Delta Kappan 1974;55(9):576–602. [10] Fox RD, Mazmanian PE, Putnam RW. Changing and learning in the lives of physicians. New York: Praeger Publishers; 1989. [11] Putnam RW, Campbell MC. Competence. In: Fox RD, Mazmanian PE, Putnam RW, editors. Changing and learning in the lives of physicians. New York: Praeger Publishers; 1989. pp. 79–97. [12] Kolb DA. Experiential learning: experience as a source of learning and development. Englewood Cliffs (NJ): Prentice-Hall; 1984. [13] Slotnick HB. How doctors learn: the role of clinical problems across the medical schoolto-practice continuum. Acad Med 1996;71(1):28–34. [14] Smith F, Singleton A, Hilton S. General practitioners’ continuing education: a review of policies, strategies and effectiveness, and their implications for the future. Br J Gen Pract 1998; 48(435):1689–95. [15] Boud D, Keogh R, Walker D, editors. Reflection: turning experience into learning. London: Kogan Page; 1985. pp. 7–17. [16] Brigley S, Young Y, Littlejohns P, et al. Continuing education for medical professionals: a reflective model. Postgrad Med J 1997;73(855):23–6. [17] Sobral DT. An appraisal of medical students’ reflection-in-learning. Med Educ 2000;34(3): 182–7. [18] Parboosingh J. Learning portfolios: potential to assist health professionals with self-directed learning. J Contin Educ Health Prof 1996;V16:75–81. [19] Clark AJ, Doig GA. The maintenance of competence programme (MOCOMP). Can J Anaesth 1993;40(6):477–9. [20] Kelly DR, MacKay L. CELT: a computerised evaluative learning tool for continuing professional development. Med Educ 2003;37:358–67. [21] Kolb DA. Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall; 1984. [22] Kell C, Van Deursen R. The fight against professional obsolescence should begin in the undergraduate curriculum. Med Teach 2000;22(2):160–3. [23] Turner P, Whitfield T. Physiotherapists’ use of evidence based practice: a cross-national study. Physiother Res Int 1997;2(1):17–29.