At the annual scientific meeting of your national specialty society, a famous textbook-writing expert in your field gives the keynote address and presents the latest research. The talk is brilliant; clearly explaining a controversial topic and suggesting changes to your practice. You listen, fascinated, for the first 30 minutes, then uncertainties arise. How comparable is this group of patients to your own? How severe are the toxicities? How would the new therapy fit in with other modalities that are used? What would it cost? If the talk runs into the next scheduled event, your queries will remain unanswered. Since learning occurs during coffee breaks at meetings, you use the opportunity to chat with colleagues (“so how do you manage these cases”?), and find that they are just as confused as you are. You return home, and continue treating the condition in the same way as before, meaning to look it up, although you have previously found it difficult to discern what is right for your patients from a literature search. And the momentum is lost. An interesting line of inquiry has come to an end.
The planners of this meeting failed to provide an opportunity for interaction between the “expert” speaker and you and your colleagues. A question period could have clarified many of the issues, and other people’s questions could have raised still more. Furthermore, the planners are not satisfying one of the conditions for accreditation of section 1 educational activities (rounds, meetings, journal clubs) in the RCPSC’s Maintenance of Certification (MOC) program. These conditions are measures that enhance learning in continuing professional development (CPD) activities by making the event relevant, and engaging the listener. The MOC program requires that “at least 25 per cent of the time of a CPD event should be allocated for interactive learning.” If the meeting offered an opportunity to follow up on the topic later in the program, it would have fulfilled that condition. If not, a good learning opportunity was missed. But this hypothetical example is not a rare experience. “Talking heads” often talk on at rounds, seminars, workshops, at the expense of audience involvement, and unintentionally promote an “us and them” perception of the experts and the ignorant who are excluded from the discussion.
The lecture format provides an efficient way of delivering new information, especially when the data must be organized into a framework, and it appeals to those with strong linguistic and verbal skills. Not all traditional continuing medical education (CME) formats are ineffectual.1,2 In their landmark meta-analysis of the effectiveness of formal CME, however, Davis et al3 show that didactic methods do not lead to a change of practice, or to an improvement in patients’ health outcomes, whereas interactive techniques do.
Why does interactivity help learning in CPD? Interaction is more than an opportunity for questions and answers after a didactic talk. It includes interpersonal communication that permits discussion, questioning, challenging, clarification, or correction. It involves communication between speaker and participant(s), and between the participants. Simpson and Galbo4 maintain that interaction is central to learning, and plays a role in activating knowledge that has been stored in memory. Thus, the speaker acts as a catalyst for learning.
Health professionals are socialized to be passive learners,5 a predictable outcome of years of lectures and memorization of endless lists of facts during training. While a few physicians may be self-directed enough to need no other types of learning activities,6 for most, the transmission of factual information is less effective than active engagement. Didactic teaching encourages passive learning, instead of the development of higher order cognitive skills. In contrast, active involvement is essential for effective learning.6,7 Adults learn best when they can tap into their previous experience, in a relevant context, using techniques such as group discussion, simulation exercises, and problem solving, instead of transmittal activities.8 Coffee-break learning occurs because education is a social process, since experience and learning are developed by interaction.9
Doing something beyond looking and listening motivates people to learn,10 and gives them the opportunity to try out new ideas, apply abstract principles to concrete situations, and critically examine issues. Articulating thoughts with colleagues allows us to see if our understanding and experiences are comparable to those of others, and to get feedback to confirm or correct faulty learning. The process of manipulating information by examining it from several perspectives helps us to process, store, and retrieve organized knowledge. These strategies to enhance learning result in information that is better retained and understood.11 Interaction provides an opportunity to spark new ideas, as other peoples’ comments “cue” recall, allowing new associations to form4 and connections between our current and our new knowledge to strengthen.11 Learners participate in the educational process, and the emphasis shifts from teaching to learning.
PRACTICAL HELP
- Faculty development courses run by university CME departments provide guidance for people who facilitate CPD.
- Rosof AB, Felch WC, editors. Continuing medical education: a primer, second edition. New York: Praeger, 1992. A book full of practical advice.
- Attending meetings, rounds, and workshops (section 1 activities). Watch for successful strategies that can be copied.
- Provide clear guidelines to invited speakers.
- Buy a podium timer.
Incorporating Interactivity into CPD
How should rounds or meeting planners incorporate interactivity into their programs? A simple way is to ensure that there is adequate time and opportunity for questions and discussion after a talk, and that this expectation is made known to the speaker in advance. Buy a timer for the podium! If it is likely that the audience may be slow to ask questions, whether sleepy or intimidated to admit ignorance, the chair has to start the ball rolling. The session chair also has the responsibility of running the question period fairly, repeating the questions if there are no microphones so that everyone can hear them, and ensuring that the questioners identify themselves, and talk in sequence. It is better if the speaker can draw the audience into the talk, posing questions, asking for a show of hands, or holding a vote on a controversial topic. This changes the audience from passive spectators to active participants. For example, incorporating a case presentation not only makes the topic more relevant for clinicians, it makes it easier for them to participate, especially if the forum is intimidating.
Rounds need not always be in a lecture format. What about trying a panel discussion, or if the topic is controversial, a lively debate? Advertise the topic in advance, ask people to bring cases or to read new guidelines, then follow up with a mini-lecture that summarizes the pertinent points. At the next rounds, ask if people found the format effective. In his excellent guide to rounds and the MOC program, Sibbald12 provides details of many techniques to make large-group learning more interactive.
At other formal CPD events such as meetings and conferences, a variety of formats may be needed for the different types of topics covered, and to accommodate participants’ diverse learning styles. It is just as important to avoid turning small group sessions, symposia, seminars, and workshops, which are naturally interactive formats, into soapboxes. A skilful facilitator and careful planning are needed to make them run smoothly. The format should match the type of learning objective; theoretical discussion may be irrelevant when learning a new technical skill in a hands-on workshop.
The technology involved in delivering distance CME, such as videoconferences and Web-based activities, is becoming increasingly sophisticated. Online and CD-ROM teaching and self-assessment modules allow access anywhere and at any hour. Videoconferencing of live events can improve access to CPD for physicians in remote communities. Since all these modalities can be impersonal, it is even more important for their designers to optimize the opportunities for interactivity and to avoid passive learning situations. Just as for face-to-face CPD, participants should have the opportunity to examine the information from different perspectives based in a clinically relevant context.13
Conclusion
Allocating time for at least 25 per cent interactive learning at a CPD event can change the educational focus from passive teaching to active learning. A boring activity merely fails to engage; an effective one should enhance the quality of health care.
References
- Silverberg J, Taylor-Vaisey A, Szalai JP, Tipping J. Lectures, interactive learning, and knowledge retention in continuing medical education. J Cont Educ Health Professions 1995;15:231-4.
- Lacoursiere Y, Snell L, McLaran J, Duarte-Franco E. Workshop versus lecture in CME: does physician learning method preference make a difference? J Cont Educ Health Professions 1997;17:141-7.
- Davis D, Thompson O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behaviour or health outcomes? JAMA 1999;282(9):867-74.
- Simpson RJ, Galbo JJ. Interaction and learning: theorizing on the art of teaching. Interchange 1986;17(4):37-51.
- Brookfield S. Critically reflective practice. J Cont Educ Health Professions 1998;18:197-205.
- Bennett NL. Adult learning: uses in CME. In: Rosof AB, Felch WC, editors. Continuing medical education: a primer, second edition. New York: Praeger, 1992:31-41.
- Harden RM, Laidlaw JM. Effective continuing education: the CRISIS criteria. Med Educ 1992;26:408-22.
- Knowles MS, Holton EF, Swanson RA. The adult learner, fifth edition. Houston: Gulf, 1998.
- Dewey J. Democracy and education. New York: The Free Press, 1996.
- Tiberius RG. Small group teaching: a trouble shooting guide. Toronto: OISE Press, 1990.
- Regehr G, Norman GR. Issues in cognitive psychology: implications for professional education. Academic Med 1996;71(9):988-1001.
- Sibbald RG, Tipping J. Rounds and maintenance of certification program. Ann R Coll Physicians Surg Can 2000;33(1):69-72.
- Kaufman DM, Brock H. Enhancing interaction using videoconferencing in continuing health education. J Cont Educ Health Professions 1998;18:81-5.
