Designing an activity for the way clinicians learn
Continuing medical education (CME) has moved from passive formats to activities built around the way clinicians learn. Such an activity rests on what is known about physicians as adult learners and the principles drawn from it. It has measurable learning outcomes, a mix of formats for learners who learn differently, faculty prepared to teach, a pre-activity component that engages learners and measures where they start, and a cycle that carries what one run of the activity teaches into the next.
From passive to interactive CME
Before 2008, CME formats were predominantly passive, and the learner was an observer. Live events offered didactic lectures from bulleted slides, with brief question-and-answer periods of single exchanges between the speaker and one learner, and in CME parlance these are L3s: lecture, lunch and leave. Internet activities were online articles followed by a post-test of whether the reader could answer questions on what they had just read.
In the past, a common assumption was that great content, conveyed once by a highly regarded authority in a single format, was enough. The provider's role ended with the activity, and participants were left to work out for themselves how to overcome any barrier to implementing what they had learned. Activities were shaped by what the faculty believed physicians should learn and how, and content was delivered in the format the faculty found most comfortable, usually a didactic lecture with bulleted slides. Physicians rarely had a chance to practise what they were taught during the activity, and programmes were not designed to aid retention and implementation.
A case with several instances of malpractice in one patient's hip replacement shows the need for a new kind of CME, one that bridges the competency gap between current performance and the gold standard of care. Three landmark reports from the Institute of Medicine have led to new mandates in medical education. The first blamed a lack of high-quality health care for thousands of unnecessary deaths from medical error, the second called for sweeping changes in health professions education, and the third, on a new health system for the twenty-first century, set out the shift and mandated new ways of teaching and learning. The mandates are four:
- Move from knowledge-based to behaviour-based education by motivating adult learners to satisfy a need and master a skill.
- Format the activity for visual, auditory, reading and kinaesthetic learning styles.
- Emphasise active formats over passive ones, to allow maximum interaction with the content.
- Use active teaching methods that engage the learner with the content before, during and after the event.
In accreditation, the shift began in about 2006, when the Accreditation Council for Continuing Medical Education (ACCME), which accredits CME providers, updated the criteria providers must meet to offer credit. Three of its criteria address learning specifically. Criterion 2 requires providers to know the educational needs, in knowledge, competence or performance, that underlie the professional practice gaps of their own learners. Criterion 4 requires the educational intervention to include content that takes into account learners' current level of knowledge, skill and experience. Criterion 19 requires providers to look beyond learning to performance and to teach physicians strategies that help them overcome obstacles to implementing what they learn. By 2012, providers were becoming aware that effective activities have to involve more than expert faculty, and they were beginning to take into account how physicians learn best in general and how to accommodate individual learners in particular.
CME quality is now judged by the degree to which it leads to improved clinical performance and better patient care. For that to happen, participants must, among other things, learn what they are taught, retain it and use it in the clinical setting. To make CME more effective, providers turned to the adult learning literature, which has long held that interactive education addressing the real-world challenges learners face is the most effective way to turn learning into behaviour change. Research on the overall efficacy of CME has shown that when programme design takes these factors into account and activities are interactive, learning translates into improved clinician competency. One CME industry figure holds that what physicians are willing to pay for is more interactive education, such as hands-on workshops and small-group peer interaction, and curricula that offer multiple opportunities to learn.
Case-based CME is one interactive format gaining in popularity. It presents learners with virtual patients in an online environment and uses guided inquiry to teach diagnostic and treatment skills and build clinical reasoning. Like role-play and simulation, it lets learners see how and why things happen, and whether their decisions at particular junctures produce beneficial or damaging outcomes. Because interactive CME can give multidimensional experiences that mimic real clinical episodes, case-based CME has proven one of the most effective ways to improve clinician performance.
Passive CME is becoming a thing of the past, which opens the door for writers to create interesting, interactive content. The profile of the CME writer is changing, and knowing how to research a topic and having a basic knowledge of disease processes are no longer enough. Providers need writers who can research the barriers the target audience faces in everyday practice and create interactive content that helps clinicians problem-solve their way to workable solutions. CME writers now write for a wider range of health professionals, covering what each needs to know and how to work in a multidisciplinary framework, and they study adult learning theory to learn how different clinicians learn.
Physicians as adult learners
For writers, the shift has required a re-examination of adult learning theory and of individual learning styles and needs. Each learner comes to an activity with their own level of knowledge and experience, their own capacity to learn and integrate new information, and a learning style that most readily helps them process and retain the content. Much of what is known about adult learning comes from models, theory and research of the 1980s and 1990s. Malcolm Knowles and K. Patricia Cross identified traits common to most, if not all, adult learners. Adult learners:
- have the ability to learn and are self-directed
- use their experience as a resource
- look for practical learning that applies to their own experience
- learn by choice
- prefer direct feedback
- have learning needs that change as their career stage changes
- learn best when information is presented in their preferred modality: visual, auditory, read-and-write or kinaesthetic
- are more likely to be motivated to learn if they understand the benefit
Physicians share these traits. So do medical writers who have trained to hone their craft or add to their skill set.
A number of factors make physicians different from adult learners of other professions. The problems they must solve are typically more complex than those other professionals address, and clinical problems are often vague or overly complex, as muscle pain or indigestion can be, and may have no readily visible solution or several. Physicians have to develop cognitive skills and ethical reasoning abilities that other professions do not require and apply them to individual patients, and a wrong decision can cause great harm or death, or lead to a malpractice suit. Although continuing education rests on principles of adult learning, it has to include elements specific to physicians. Physicians learn best when education occurs in the context of patient care, applies directly to clinical problems they are trying to solve, accommodates the limits on their time, includes an opportunity for individual feedback, and provides strategies for overcoming barriers that may prevent recommendations being implemented. Activities written with these factors in mind can be very effective in improving practice performance and patient outcomes. Clinicians who choose learning opportunities that reflect their own values and passion for patient care are more likely to feel motivated and engaged in their professional growth.
Principles of physician learning
Three key principles should guide the delivery of effective medical education. First, learners must acknowledge that they need to learn and understand clearly what they are going to learn, so the activity needs clearly stated and relevant objectives that tell them what they need to learn, how the activity addresses that need and how it will benefit them. Second, learning cannot be purely didactic, so an effective activity should include a practical element in which learners practise what they have learnt. Third, education needs to take into account the different ways people learn and their preferences about how they want to learn.
The best CME writers follow seven principles of physician learning, adapted from several adult learning theories:
- Physicians are more likely to learn if they understand their own gaps in competency. Give them opportunities to reflect on their practice, analysing and assessing their own performance against best-practice standards. Given that opportunity, they are more likely to be motivated to learn and to change their practice.
- Focus the activity on clinical problems and supply information usable in practice. Most physicians are continually searching for information that helps them solve specific patient problems or improve their practice in general. The goal is improvement of actual practice, not just retention of new information, and research shows that physicians are more likely to learn and change behaviour the more closely the content addresses the clinical problems they encounter.
- Interaction with other learners reinforces learning and increases the potential for practice improvement. Most physicians work in social environments where interaction with colleagues is possible and common, so an activity that offers interaction with other learners as well as with the content is more effective.
- Provide opportunities for active learning. Medical education has historically depended almost exclusively on didactic lectures and printed material, in which the learner is an observer absorbing what is presented, but physicians learn best by doing. Active learning recreates the social environment in which the new information will be used, provides practice and feedback, and keeps learners engaged.
- Take account of what the learners already know. Physicians learn in relation to what they know and have experienced, and each arrives with different walking-in-the-door knowledge, so content that takes this into account brings novices' learning curves closer to those of more experienced participants.
- Allow practice and provide feedback. The activity must give opportunities to practise what is taught and encourage self-assessment and constructive feedback from teachers and peers. Practice and feedback prompt reflection on the task and show the learner how to improve their practice.
- Engage learners before and after the activity, not only during it. Translation of learning into practice is more likely when physicians are engaged before and after an activity. Learning complex clinical content takes more than one exposure, and the best programmes engage learners before the activity starts and after it ends, which enhances learning and application of what is taught and allows an assessment of how effective the education was in improving clinical practice.
Learning outcomes
The writer helps develop actionable learning outcomes that tie the identified knowledge or practice gaps to the intended learning. In one experienced writer's account, the outcomes can come from the provider or from the writer, depending on the proposed event and its final deliverable. To develop effective learning outcomes, a writer should know how to use Bloom's revised taxonomy, a two-dimensional framework of measurable verbs that classify cognitive learning, with the emphasis on active learning. With it, a vague outcome such as "understand insulin therapy" becomes a measurable task such as "demonstrate effective insulin dose titration". Writers work closely with the faculty experts invited to present an activity, and that collaboration shapes the educational content. A good working relationship with the rest of the educational team is critical to identifying major gaps in knowledge, such as awareness of a new guideline, and fundamental to shaping a session's focus and learning outcomes.
Formats
One way the delivery of medical education has evolved is a deeper understanding of the different adult learning styles, and programmes designed to address them. In 1986, Honey and Mumford proposed four main adult learning styles. An activist likes new experiences and ideas and enjoys collaborative group learning. A reflector likes considering different perspectives and enjoys listening to others. A theorist likes step-by-step analytical approaches and enjoys testing learned ideas by applying them to practical situations. A pragmatist likes ideas with immediate applicability and enjoys hands-on testing and practice. A programme therefore has to speak to all four, with a mix of plenary presentations, case-study-based discussions, practical hands-on sessions and interactive breakout workshops. For example, one standalone event, supported by an educational grant from a company marketing several oncology products, used keynote plenary presentations by key thought leaders for an overview of the disease area and treatment landscape, breakout workshops on clinical challenges, case-study-based discussions to find the best strategy in hard-to-treat patients, and interactive keypad voting throughout to capture attendee opinions and how they changed as a result of the programme. Variety in delivery makes attendees more likely to retain the programme's educational messages.
The educational format should match the learning objectives. A learner who needs a new skill should practise it through simulation or real-life experience rather than only read about it. Adults learn better when they contribute actively and practise what they are learning, and feedback from faculty and peers, in a setting that lets them reflect, helps solidify what they learned. Commonly used teaching strategies depend on the level of the learning objective in Bloom's taxonomy:
| Level | Teaching strategies |
|---|---|
| Create | Projects, problems, case studies, creative exercises, developing plans, simulations |
| Evaluate | Case studies, projects, exercises, critiques, simulations, appraisals |
| Analyse | Problems, exercises, case studies, critical incidents, discussion, questions, tests |
| Apply | Exercises, practice, projects, simulations, role play, microteaching |
| Understand | Questioning, discussion, tests, assessment, learner presentations, writing |
| Remember | Lectures, visuals, video, audio, examples, illustrations, analogies |
In recent years, multimedia and gamification have emerged as training platforms for CME, and gamification platforms such as educational games, mobile applications and virtual patient simulations can be used to increase engagement and enhance collaboration.
Real patients and live technique demonstrations are a powerful teaching tool that is not often used in CME. One programme on facial rejuvenation was designed around a robust needs assessment, sound adult learning concepts, best practice in patient care, and the needs that arise where facial anatomy, aesthetic evaluation, the injection device and product characteristics meet. Its activities built on one another, as participants progressed from didactic presentations with audience participation and immediate peer feedback, to video, to live patient injection sessions. It was offered online, which let it reach an international audience. Assessment measured specific changes against a baseline taken before the activity, and a later follow-up assessed whether the programme's concepts and tactics were applied in clinical practice.
Its developers report that, in other clinical education settings, the same model achieved a far greater level of competency than a lecture-only presentation would have. In one activity, the share of participants who correctly identified skin lesions rose from 19% before the activity to 62% after working with live patients. Writers of content for live programmes are often challenged to fit effective educational activities into brief clinical experiences. CME providers should explore how to use the model in different therapeutic settings, since its best use may differ between clinical scenarios.
Medical education uses ever-changing technologies to implement the final deliverable. Over the ten years to 2026, delivery moved from lecture-style recordings with slide decks to interactive, conversational sessions with groups of experts. For one client, switching from lecture videos to interactive panel discussions brought livelier case debate and positive reviews from attendees. Since the COVID-19 pandemic, providers have had to adopt new formats and platforms, so a successful project now needs more understanding of the audience and how it uses different modalities and technologies. Whether a programme is a conference workshop or a podcast series of bite-size content, its objective is the same: to deliver relevant updates or encourage clinicians to rethink established practices in ways that directly enhance patient care. Typical CME project types differ in main audience and deliverables:
| Project type | Main audience | Example deliverables |
|---|---|---|
| Conference workshop | Physicians, nurses | Slide decks, case studies |
| Podcast series | Multidisciplinary | Scripts, learning outcomes |
| Online modules | Allied health professionals | Interactive scenarios |
| Live panel events | Specialists | Question-and-answer guides, presentations |
Faculty
The topics to be covered and who will speak about them are generally what draws a learner to an educational event. Key thought leaders remain the most effective way to deliver education to practising physicians, so the first question in developing a programme is whom the audience most wants to learn from, and those people are involved in delivering it wherever possible.
The skill of the educator is also crucial to an activity's success, so training the trainer is an important step in preparing it. Where peer-to-peer education works best, programmes are often delivered by thought leaders whose experience as educators varies. They should be involved from the outset, so that they can contribute to the educational objectives, and they should be given guidance on how best to present or facilitate particular sessions. Linking that guidance to the activity's educational content can deliver it in a setting where the trainer is more likely to be receptive.
The pre-activity component
One activity that incorporates many of these principles aimed to improve how primary-care physicians at a regional health maintenance organisation treat chronic non-cancer pain with opioid therapy. Those physicians had already received best-practice information on pain management through guidelines, presentations, workshops, letters and computer programs, and few changes had followed. The literature on learning and CME predicts this: making information available does not mean it is conveyed, and conveying it does not mean recipients act on it.
Its pre-activity component relies on proven methods of active learning to ensure that physicians receive, master and apply best practices for patient care. It has three phases and is posted online three weeks before the activity. In the first, learners complete a survey of what they know about the treatment and how they currently treat patients with the condition. In the second, they review three case vignettes, each two or three paragraphs on the source of the pain, the history of treatment and any special characteristics of the patient, mixed so that the correct treatment is neither simple nor obvious. They choose a treatment through multiple-choice questions, and faculty then give feedback based on established clinical guidelines. In the third, learners briefly describe how their treatment differs, if at all, from guideline recommendations, how patients can benefit from implementing them, and how their practice could improve through more effective pain care.
The component has learners reflect on their current practice and the gap between what they do and what they should do, which prepares them for the activity and motivates them to learn and change their practice. It gives an initial measurement of competence to compare with competence after the activity, to determine whether the stated learning objectives have been reached. Its results show the knowledge and practice of each learner, which helps the faculty match the course material to the audience's background.
The design cycle
Continuing education has not always used the findings of the learning sciences or changed clinical behaviour. Writers can help make it engaging and learner-centred by following principles of instructional design and building conceptual frameworks into the activity, commonly the plan-do-study-act (PDSA) cycle, Bloom's taxonomy and Moore's levels. The PDSA cycle, commonly used to design CME activities, is built to assess and improve continually. In the plan phase, a needs assessment identifies practice gaps and educational needs, and the activity is designed from its findings; in the do phase, clinicians take part in the activity; in the study phase, educators evaluate its effectiveness through test questions, surveys or open-ended questions; and in the act phase, those insights can be built into the activity for later groups of learners. The analysis, design, development, implementation and evaluation (ADDIE) model is a closely similar five-step model, and both continually feed back into the activity to strengthen the link between education and clinical behaviour.