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Provider EducationProvider Educationand and
Behavior ChangeBehavior Changemichael wilkes, md, phdmichael wilkes, md, phd
professor of medicine and medical educationprofessor of medicine and medical educationuniversity of californiauniversity of california
Provider EducationProvider Educationand and
Behavior ChangeBehavior Changemichael wilkes, md, phdmichael wilkes, md, phd
professor of medicine and medical educationprofessor of medicine and medical educationuniversity of californiauniversity of california
2
PROBLEMPROBLEMPROBLEMPROBLEMo Proliferation in volume and complexity of Proliferation in volume and complexity of
biomedical knowledge and technologybiomedical knowledge and technologyo Increased clinical pressures including Increased clinical pressures including
documentation, volume, and monitoringdocumentation, volume, and monitoringo Physicians need to maintain currency but Physicians need to maintain currency but
don’t know howdon’t know how
o Proliferation in volume and complexity of Proliferation in volume and complexity of biomedical knowledge and technologybiomedical knowledge and technology
o Increased clinical pressures including Increased clinical pressures including documentation, volume, and monitoringdocumentation, volume, and monitoring
o Physicians need to maintain currency but Physicians need to maintain currency but don’t know howdon’t know how
Adult LearningAdult LearningAdult LearningAdult Learning
Michael WilkesMichael WilkesMichael WilkesMichael Wilkes
Instructional Design Instructional Design PrinciplesPrinciples
Instructional Design Instructional Design PrinciplesPrinciples
o The best instruction is that which is:The best instruction is that which is:o Effective Effective - - facilitates learners’ acquisition offacilitates learners’ acquisition of
the prescribed knowledge, skills and attitudes the prescribed knowledge, skills and attitudes o Efficient Efficient – requires the least possible amount– requires the least possible amount
of time necessary for learners to achieve theof time necessary for learners to achieve theobjective objective
o Appealing Appealing – motivates and interests learners,– motivates and interests learners,encourages them to persevere in the learningencourages them to persevere in the learningtask task
o EnduringEnduring – encoded in long-term memory,– encoded in long-term memory,accessible and applicable in the futureaccessible and applicable in the future
o The best instruction is that which is:The best instruction is that which is:o Effective Effective - - facilitates learners’ acquisition offacilitates learners’ acquisition of
the prescribed knowledge, skills and attitudes the prescribed knowledge, skills and attitudes o Efficient Efficient – requires the least possible amount– requires the least possible amount
of time necessary for learners to achieve theof time necessary for learners to achieve theobjective objective
o Appealing Appealing – motivates and interests learners,– motivates and interests learners,encourages them to persevere in the learningencourages them to persevere in the learningtask task
o EnduringEnduring – encoded in long-term memory,– encoded in long-term memory,accessible and applicable in the futureaccessible and applicable in the future
Arteries and veins Arteries and veins Arteries and veins Arteries and veins o Arteries:Arteries:
o Are more elastic than veinsAre more elastic than veinso Carry more blood than veinsCarry more blood than veinso Are less elastic than veinsAre less elastic than veinso A and BA and Bo B and CB and C
o Arteries:Arteries:o Are more elastic than veinsAre more elastic than veinso Carry more blood than veinsCarry more blood than veinso Are less elastic than veinsAre less elastic than veinso A and BA and Bo B and CB and C
What is the goal of learning?What is the goal of learning?What is the goal of learning?What is the goal of learning?o Facts are important (chess, surgery, Facts are important (chess, surgery,
math)math)o Usable knowledge is not the same as Usable knowledge is not the same as
disconnected facts;disconnected facts;o Need connections and organization to Need connections and organization to
promote transfer to other contexts rather promote transfer to other contexts rather than just memorythan just memoryo Why do arteries and veins have those Why do arteries and veins have those
properties? Know structure and fxproperties? Know structure and fx
o Facts are important (chess, surgery, Facts are important (chess, surgery, math)math)
o Usable knowledge is not the same as Usable knowledge is not the same as disconnected facts;disconnected facts;
o Need connections and organization to Need connections and organization to promote transfer to other contexts rather promote transfer to other contexts rather than just memorythan just memoryo Why do arteries and veins have those Why do arteries and veins have those
properties? Know structure and fxproperties? Know structure and fx
KnowingKnowingKnowingKnowingo Humans are goal directed and seek Humans are goal directed and seek
informationinformationo We come to education with prior We come to education with prior
experiences, knowledge, beliefs, etc.experiences, knowledge, beliefs, etc.o This impacts what we notice and how we This impacts what we notice and how we
organize itorganize ito Which impacts how we remember, reason, Which impacts how we remember, reason,
solve problems and acquire new knowledgesolve problems and acquire new knowledge
o Humans are goal directed and seek Humans are goal directed and seek informationinformation
o We come to education with prior We come to education with prior experiences, knowledge, beliefs, etc.experiences, knowledge, beliefs, etc.
o This impacts what we notice and how we This impacts what we notice and how we organize itorganize it
o Which impacts how we remember, reason, Which impacts how we remember, reason, solve problems and acquire new knowledgesolve problems and acquire new knowledge
Ways to earn CMEWays to earn CMEWays to earn CMEWays to earn CME
Most common: live conference
Ways to earn CMEWays to earn CMEWays to earn CMEWays to earn CME
o Live CoursesLive Courseso In-hospital programsIn-hospital programso Pharm sponsored meetings (Pri-Med)Pharm sponsored meetings (Pri-Med)o Enduring Materials (DVDs), JournalsEnduring Materials (DVDs), Journalso CME Online (new guy on street both CME Online (new guy on street both
synchronous and asynchronous) synchronous and asynchronous) o ““Just in time” appsJust in time” apps
o Live CoursesLive Courseso In-hospital programsIn-hospital programso Pharm sponsored meetings (Pri-Med)Pharm sponsored meetings (Pri-Med)o Enduring Materials (DVDs), JournalsEnduring Materials (DVDs), Journalso CME Online (new guy on street both CME Online (new guy on street both
synchronous and asynchronous) synchronous and asynchronous) o ““Just in time” appsJust in time” apps
Three TeachersThree TeachersThree TeachersThree Teacherso A: Teacher’s goal to get doctors to use Shared A: Teacher’s goal to get doctors to use Shared
Decision-making skills Decision-making skills ((oversees and monitors work – focus on product and process)
o B: Gives lectures and exams - assumes B: Gives lectures and exams - assumes responsibility for learning responsibility for learning ((attends to what students are learning and monitors))
o C: Give students objectives/competencies and C: Give students objectives/competencies and leaves learning to students to self assess leaves learning to students to self assess (available for feedback and consultation)
o A: Teacher’s goal to get doctors to use Shared A: Teacher’s goal to get doctors to use Shared Decision-making skills Decision-making skills ((oversees and monitors work – focus on product and process)
o B: Gives lectures and exams - assumes B: Gives lectures and exams - assumes responsibility for learning responsibility for learning ((attends to what students are learning and monitors))
o C: Give students objectives/competencies and C: Give students objectives/competencies and leaves learning to students to self assess leaves learning to students to self assess (available for feedback and consultation)
What is being learned?What is being learned?What is being learned?What is being learned?o Teacher A?Teacher A?o Teacher B?Teacher B?o Teacher C?Teacher C?
o Teacher A?Teacher A?o Teacher B?Teacher B?o Teacher C?Teacher C?
LearningLearningLearningLearningo Teacher A (hospital system):Teacher A (hospital system):
o Learning to do tasks and turn in material on Learning to do tasks and turn in material on time but the timeline and task may get in time but the timeline and task may get in the way. the way.
o Teacher B (CME):Teacher B (CME):o Working to provide information in lectures Working to provide information in lectures
and document recall.and document recall.o Teacher C (adult learning): Teacher C (adult learning):
o learning is outgrowth of what is needed – learning is outgrowth of what is needed – most of this work is done before the most of this work is done before the exerciseexercise
o Teacher A (hospital system):Teacher A (hospital system):o Learning to do tasks and turn in material on Learning to do tasks and turn in material on
time but the timeline and task may get in time but the timeline and task may get in the way. the way.
o Teacher B (CME):Teacher B (CME):o Working to provide information in lectures Working to provide information in lectures
and document recall.and document recall.o Teacher C (adult learning): Teacher C (adult learning):
o learning is outgrowth of what is needed – learning is outgrowth of what is needed – most of this work is done before the most of this work is done before the exerciseexercise
Principles of Andragogy Principles of Andragogy Principles of Andragogy Principles of Andragogy Adults Adults oNeed to be involved in the planning andNeed to be involved in the planning andevaluation of their instruction.evaluation of their instruction.oNeed to know why they need to know something;Need to know why they need to know something;oLearn best through self-discovery with real and Learn best through self-discovery with real and simulated experiencessimulated experiencesoMotivation is greatest when it is internal and when Motivation is greatest when it is internal and when an activity presents new knowledge applicable to an activity presents new knowledge applicable to real lifereal lifeoHave an independent self-concept, take Have an independent self-concept, take responsibility for their lives, are self-directed, and responsibility for their lives, are self-directed, and have a deep need to control learning.have a deep need to control learning.o
Adults Adults oNeed to be involved in the planning andNeed to be involved in the planning andevaluation of their instruction.evaluation of their instruction.oNeed to know why they need to know something;Need to know why they need to know something;oLearn best through self-discovery with real and Learn best through self-discovery with real and simulated experiencessimulated experiencesoMotivation is greatest when it is internal and when Motivation is greatest when it is internal and when an activity presents new knowledge applicable to an activity presents new knowledge applicable to real lifereal lifeoHave an independent self-concept, take Have an independent self-concept, take responsibility for their lives, are self-directed, and responsibility for their lives, are self-directed, and have a deep need to control learning.have a deep need to control learning.o
Experiential Learning Principles Experiential Learning Principles Experiential Learning Principles Experiential Learning Principles o Significant learning takes place when the Significant learning takes place when the
subject matter is relevant to the personal subject matter is relevant to the personal interests of the student interests of the student
o Learning which is threatening to the self Learning which is threatening to the self (e.g., new attitudes or perspectives) is more (e.g., new attitudes or perspectives) is more easily assimilated when external threats are easily assimilated when external threats are minimized minimized
o Learning proceeds faster when the threat to Learning proceeds faster when the threat to the self is low; the self is low;
o Self-initiated learning is the most lasting Self-initiated learning is the most lasting andandpervasive.pervasive.
o Significant learning takes place when the Significant learning takes place when the subject matter is relevant to the personal subject matter is relevant to the personal interests of the student interests of the student
o Learning which is threatening to the self Learning which is threatening to the self (e.g., new attitudes or perspectives) is more (e.g., new attitudes or perspectives) is more easily assimilated when external threats are easily assimilated when external threats are minimized minimized
o Learning proceeds faster when the threat to Learning proceeds faster when the threat to the self is low; the self is low;
o Self-initiated learning is the most lasting Self-initiated learning is the most lasting andandpervasive.pervasive.
Cognitive Learning PrinciplesCognitive Learning PrinciplesCognitive Learning PrinciplesCognitive Learning Principleso Learning activities must provide multipleLearning activities must provide multiple
representations of content representations of content o Instructional materials should avoid Instructional materials should avoid
oversimplifying the content domain and oversimplifying the content domain and support support context-dependent context-dependent knowledge knowledge
o Instruction should be Instruction should be case-based case-based and and emphasizeemphasizeknowledge constructionknowledge construction, not transmission of, not transmission ofinformationinformation
o Knowledge should be highly Knowledge should be highly interconnected interconnected rather than compartmentalized.rather than compartmentalized.
o Learning activities must provide multipleLearning activities must provide multiplerepresentations of content representations of content
o Instructional materials should avoid Instructional materials should avoid oversimplifying the content domain and oversimplifying the content domain and support support context-dependent context-dependent knowledge knowledge
o Instruction should be Instruction should be case-based case-based and and emphasizeemphasizeknowledge constructionknowledge construction, not transmission of, not transmission ofinformationinformation
o Knowledge should be highly Knowledge should be highly interconnected interconnected rather than compartmentalized.rather than compartmentalized.
AssessmentAssessmentAssessmentAssessmento FootprintsFootprints (EMR documentation, (EMR documentation,
mammograms, BRCA test ordering)mammograms, BRCA test ordering)o KnowledgeKnowledge (MCQs) (MCQs)o AttitudesAttitudes (surveys, OSVEs, 360 (surveys, OSVEs, 360
evals)evals)o Behaviors Behaviors (OSCEs or SP visits)(OSCEs or SP visits)o Self Assessment*Self Assessment*
o FootprintsFootprints (EMR documentation, (EMR documentation, mammograms, BRCA test ordering)mammograms, BRCA test ordering)
o KnowledgeKnowledge (MCQs) (MCQs)o AttitudesAttitudes (surveys, OSVEs, 360 (surveys, OSVEs, 360
evals)evals)o Behaviors Behaviors (OSCEs or SP visits)(OSCEs or SP visits)o Self Assessment*Self Assessment*
Self Assessment: The RealitySelf Assessment: The RealitySelf Assessment: The RealitySelf Assessment: The Reality
o Hundreds of articlesHundreds of articleso Many literature reviewsMany literature reviewso One conclusion:One conclusion:
Self-assessment ability Self-assessment ability is generally pooris generally poor
o Hundreds of articlesHundreds of articleso Many literature reviewsMany literature reviewso One conclusion:One conclusion:
Self-assessment ability Self-assessment ability is generally pooris generally poor
Three Three Key PatternsKey Patterns of Data of DataThree Three Key PatternsKey Patterns of Data of Data
o Little or no relationship between Little or no relationship between externally generated scores and self-externally generated scores and self-assessed scoresassessed scoresAll but the very highest performers All but the very highest performers tend to overestimate abilitytend to overestimate abilityWorst offenders are in lowest quartile Worst offenders are in lowest quartile of performanceof performance
o Little or no relationship between Little or no relationship between externally generated scores and self-externally generated scores and self-assessed scoresassessed scoresAll but the very highest performers All but the very highest performers tend to overestimate abilitytend to overestimate abilityWorst offenders are in lowest quartile Worst offenders are in lowest quartile of performanceof performance
The The Rhetoric Rhetoric of Self-Assessmentof Self-AssessmentThe The Rhetoric Rhetoric of Self-Assessmentof Self-Assessmento Adult education literature promotes Adult education literature promotes
expertise as a process of effective self-expertise as a process of effective self-reflectionreflectiono Lifelong, self-directed learnersLifelong, self-directed learners
o The health professions have embraced a The health professions have embraced a philosophy of professional autonomy and philosophy of professional autonomy and self-regulationself-regulationo ““Demands competent and trustworthy Demands competent and trustworthy
self-assessment by members”self-assessment by members”
o Adult education literature promotes Adult education literature promotes expertise as a process of effective self-expertise as a process of effective self-reflectionreflectiono Lifelong, self-directed learnersLifelong, self-directed learners
o The health professions have embraced a The health professions have embraced a philosophy of professional autonomy and philosophy of professional autonomy and self-regulationself-regulationo ““Demands competent and trustworthy Demands competent and trustworthy
self-assessment by members”self-assessment by members”
o ““Unskilled and unaware”Unskilled and unaware”o The skills required to The skills required to knowknow whether you whether you
are performing well are also the skills are performing well are also the skills required to required to actuallyactually perform well perform well
o ““Unskilled and unaware”Unskilled and unaware”o The skills required to The skills required to knowknow whether you whether you
are performing well are also the skills are performing well are also the skills required to required to actuallyactually perform well perform well
Kruger & Dunning Kruger & Dunning (1999)(1999)Kruger & Dunning Kruger & Dunning (1999)(1999)
eDoctoringeDoctoringeDoctoringeDoctoring
Personalized NewsVideo MailsPersonalized NewsVideo Mails
Health and Safety MonitoringParents Update
Health and Safety MonitoringParents Update
CommuteEmail / VoiceLeisure Time
CommuteEmail / VoiceLeisure Time
Physical / VirtualPhysical / Virtual
New DeliveryModelsNew DeliveryModelsEmployee MeetingEmployee Meeting
Customer MeetingCustomer Meeting
The New World: On The Human NetworkConnected Anywhere, Anytime, Any DeviceThe New World: On The Human NetworkConnected Anywhere, Anytime, Any Device
Students, Residents, Doctors, Adminstrators, Parents…Students, Residents, Doctors, Adminstrators, Parents…
On Line EducationOn Line EducationOn Line EducationOn Line Educationo Doctors have little timeDoctors have little timeo Interested in behavioral change not Interested in behavioral change not
just knowledgejust knowledgeo Best practice / poor practiceBest practice / poor practiceo Safe environment where they can Safe environment where they can
be engagedbe engagedo Active involvement and self-Active involvement and self-
managed learningmanaged learning
o Doctors have little timeDoctors have little timeo Interested in behavioral change not Interested in behavioral change not
just knowledgejust knowledgeo Best practice / poor practiceBest practice / poor practiceo Safe environment where they can Safe environment where they can
be engagedbe engagedo Active involvement and self-Active involvement and self-
managed learningmanaged learning
AssessmentAssessmentAssessmentAssessmento What do doctors actually do with What do doctors actually do with
patients?patients?o Prior data from PCa shows doctors Prior data from PCa shows doctors
report behaviors that patients report behaviors that patients report are not practicedreport are not practiced
o Data shows that doctors over-rate Data shows that doctors over-rate their engagement and interaction their engagement and interaction compared to patientscompared to patients
o What do doctors actually do with What do doctors actually do with patients?patients?
o Prior data from PCa shows doctors Prior data from PCa shows doctors report behaviors that patients report behaviors that patients report are not practicedreport are not practiced
o Data shows that doctors over-rate Data shows that doctors over-rate their engagement and interaction their engagement and interaction compared to patientscompared to patients
Is our program effective?Is our program effective?Is our program effective?Is our program effective?
Knowledge
Acquisition
Knowledge
Retention
PracticeImproveme
nt
EnhancedPatient
Outcomes
Catherine DouglasCatherine Douglaso Age: 41o Gender: Femaleo Race: Caucasiano Education: Some collegeo Employment: real estate appraisero Reason for visit: o “My sister was recently diagnosed with breast
cancer. Although I am very concerned about her, I was wondering how much I have to worry about getting breast cancer myself?”
o Age: 41o Gender: Femaleo Race: Caucasiano Education: Some collegeo Employment: real estate appraisero Reason for visit: o “My sister was recently diagnosed with breast
cancer. Although I am very concerned about her, I was wondering how much I have to worry about getting breast cancer myself?”
WHAT DO WE LOOK FOR?WHAT DO WE LOOK FOR?WHAT DO WE LOOK FOR?WHAT DO WE LOOK FOR?o Open ended questions?Open ended questions?o Balance and framingBalance and framingo Use of simple, understandable language?Use of simple, understandable language?o Checking on patient’s understanding?Checking on patient’s understanding?o Values clarification / shared decisions?Values clarification / shared decisions?o Factual accuracy / truthfulnessFactual accuracy / truthfulnesso Medical topics Medical topics (risks/benefits, confidentiality, (risks/benefits, confidentiality,
cost, implications of a pos / neg result….) cost, implications of a pos / neg result….)
o Open ended questions?Open ended questions?o Balance and framingBalance and framingo Use of simple, understandable language?Use of simple, understandable language?o Checking on patient’s understanding?Checking on patient’s understanding?o Values clarification / shared decisions?Values clarification / shared decisions?o Factual accuracy / truthfulnessFactual accuracy / truthfulnesso Medical topics Medical topics (risks/benefits, confidentiality, (risks/benefits, confidentiality,
cost, implications of a pos / neg result….) cost, implications of a pos / neg result….)
Do people like CME Online? Do people like CME Online? Do people like CME Online? Do people like CME Online? o Yes!Yes!
o 98% would recommend to a colleague98% would recommend to a colleagueo Number one recommendation for Number one recommendation for
how to improve: add more caseshow to improve: add more caseso Hundreds of quotes from satisfied Hundreds of quotes from satisfied
participantsparticipantso High ratings in evaluation surveysHigh ratings in evaluation surveyso Willing to pay for it!Willing to pay for it!
o Yes!Yes!o 98% would recommend to a colleague98% would recommend to a colleague
o Number one recommendation for Number one recommendation for how to improve: add more caseshow to improve: add more cases
o Hundreds of quotes from satisfied Hundreds of quotes from satisfied participantsparticipants
o High ratings in evaluation surveysHigh ratings in evaluation surveyso Willing to pay for it!Willing to pay for it!
SummarySummarySummarySummary
o Physician participation in online Physician participation in online CME is increasing each yearCME is increasing each year
o Our program evaluations show Our program evaluations show knowledge acquisition, application knowledge acquisition, application of learning, and behavior changeof learning, and behavior change
o More work is needed to assess More work is needed to assess patient outcomespatient outcomes
o More work to be done with smart More work to be done with smart phone apps…phone apps…
o Physician participation in online Physician participation in online CME is increasing each yearCME is increasing each year
o Our program evaluations show Our program evaluations show knowledge acquisition, application knowledge acquisition, application of learning, and behavior changeof learning, and behavior change
o More work is needed to assess More work is needed to assess patient outcomespatient outcomes
o More work to be done with smart More work to be done with smart phone apps…phone apps…
The End
Analysis of the LearnerAnalysis of the LearnerAnalysis of the LearnerAnalysis of the Learnero Who is your target audience? Who is your target audience? o Cognitive characteristics Cognitive characteristics o Specific content knowledge Specific content knowledge o Prior experiences Prior experiences o Physiological characteristicsPhysiological characteristics
n Agen Agen Sensory perceptionn Sensory perceptionn General healthn General healthn Psychosocia characteristicsn Psychosocia characteristicsn Interestsn Interestsn Motivationsn Motivationsn Attitude toward learningn Attitude toward learningn Moral developmentn Moral developmentn Job position and rankn Job position and rankn Role Modelsn Role Models
o Gagne, R., Briggs, L. & Wager, W. (1992). Principles of Instructional DesignGagne, R., Briggs, L. & Wager, W. (1992). Principles of Instructional Designvv
o Who is your target audience? Who is your target audience? o Cognitive characteristics Cognitive characteristics o Specific content knowledge Specific content knowledge o Prior experiences Prior experiences o Physiological characteristicsPhysiological characteristics
n Agen Agen Sensory perceptionn Sensory perceptionn General healthn General healthn Psychosocia characteristicsn Psychosocia characteristicsn Interestsn Interestsn Motivationsn Motivationsn Attitude toward learningn Attitude toward learningn Moral developmentn Moral developmentn Job position and rankn Job position and rankn Role Modelsn Role Models
o Gagne, R., Briggs, L. & Wager, W. (1992). Principles of Instructional DesignGagne, R., Briggs, L. & Wager, W. (1992). Principles of Instructional Designvv
confidentialityconfidentialityconfidentialityconfidentiality
