Author: Brian S McGowan, PhD

For as long as I have been teaching, creating medical education, or even funding education there has always been one assumption that has bothered me about what we broadly refer to as ‘adult learning,’ and that is the assumption that adults KNOW how to learn. This assumption is all the more critical when we move from a singular focus on adult learning theory and begin to focus the more practical learning actions.

To put the critical reality of this assumption in context using just a small example of physician education: Each year in the US there are more than 100,000 different activities planned and implemented by ACCME-accredited providers totaling nearly 1,000,000 hours of medical education. The costs in terms of finances and energies is nearly impossible to calculate. And, in what may be the understatement of the year, this is a pretty weighty model to base on an assumption.

Now, if the assumption is valid, then ‘no harm done’ and we might just as well be content with the efficiency and effectiveness of the existing model of lifelong learning in the health professions. But if the assumption is invalid, well then this one issue (do clinicians really know how to learn) might go a long way to explaining why we continue to hear about a ‘broken and fragmented‘ system of lifelong learning and why CME in particular has been referred to as ‘minimally’ or ‘generally’ effective.

So as we began our recent research into clinician lifelong learning – the same research that lead to what we have come to call the Natural Learning Actions – we began to ask clinicians how efficiently and effectively they leveraged each of these actions.

Here are the average grades that the clinician learners gave themselves:

Note-taking:   C-

Setting Reminders/
Reflection:   F

Search:   C-

Social Learning:   C-

Read through those grades one more time! As clinicians began to reflect on how critical the learning actions were to their ability to efficiently and effectively absorb and take action on new information, they just as quickly came to the realization that they hadn’t spent much time honing these learning actions. Not one clinician in our interviews had ever taken a course on note-taking. Fewer than 1 in 20 had ever taken a course in ‘search’. Here we are assuming for as long as I can tell that learners – especially learners with the intelligence and passion of physicians – know how to learn when by the own volition, this is far from the reality.

I have been chewing on this new view of lifelong learning in the healthcare professions for several months now and these findings are in no way a condemnation of clinician learners or medical educators – it is simply a logical, but faulty, assumption that we now know has long been undermining our educational models. Surely clinicians have learned through existing undergraduate and lifelong learning opportunities. Surely some of the most critical lessons stick. But what we have come to learn is that by nudging our learners to take notes, set reminders, search for related context, and engage with other learners we may make learning much more efficient and effective.

Over the coming months our research will undoubtedly bear this out. But in the meantime I continue to look for other evidence to support (or refute) our new model, which leads me to my final thought. With this new context in mind, go ahead and read this statement recently published in Medical Teacher by faculty at Johns Hopkins:

Reflection is a skill that requires teaching and practice. It is within the explicit process of teaching reflection in medical education that reflective learners can be developed.

It may come as no surprise but I support this notion whole-heartily. Note-taking is a skill. Setting reminders and reflection systems is a skill. Searching for related context is a skill. And engaging effectively with other learners to co-create knowledge is a skill. Each of these learning actions is a skill that must be trained, honed, refined, and occasionally nudged. And in a lifelong learning system where these skills can be optimized, so to will be learning.