Tag: adult learning

“We Don’t Need Compliance, We Need Collaboration” and Personalized Learning

The Health Care Blog posted the following “Population Health Isn’t Working Out Quite the Way They Said It Would. What’s Going On?” Authored by Hilary R. Hatch, Ph.D. from Vital Score, Inc.

I agree with all that Hatch presented especially the headline quote. It is all about collaboration. Her primary premiss is that we are putting patients into categories by conditions (i.e. diabetes, heart disease, etc.) when patients with the same conditions are different. She gives the example of depression and notes that for her depression is a billing condition and not relevant to treatment planning for a vast array of patients, those in mourning, postpartum moms, isolated geriatric patient, etc. Hatch further addressed how population health is failing in the physicians office.

“When the population health need gets attention, is it at the expense of the individual’s need? Care plans driven by population health diagnostic categories are more formulaic, symptom-focused and may ignore root causes. As such, they are less likely to be successful. Then, when patients fail in flawed care plans, we indulge in blaming and name-calling: “non-compliant” or “non-adherent.”

Hatch continues her logic with the thought that non-adherence is resistance by the patient to different forces such as cost, the patient sense the drug or therapy is not working, and other factors. Her solution and rightly so is to help patients ‘choose their own adventure’ to identify their pathways to health and success.

“…when people self-identify needs and self-refer to services, their participation rate increases up to 20x. People own their choices because their choices are personally driven for their own benefit. It’s not only better for workflow, it’s better for outcomes.”

In my opinion Hatch argues clearly and is spot on when it comes to motivating patients. It is all about self-identified goals and management from the bottom up (patient) not the top down (HCP). But I would add to this the work of Malcolm Knowles who studied how adults learn. If we understand and use adult learning we can improve patient motivation.

Knowles characterized adult learning as follows:
  1. Self-concept: As a person matures his self concept moves from one of being a dependent personality toward one of being a self-directed human being
  2. Experience: As a person matures he accumulates a growing reservoir of experience that becomes an increasing resource for learning.
  3. Readiness to learn. As a person matures his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles.
  4. Orientation to learning. As a person matures his time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem centredness.
  5. Motivation to learn: As a person matures the motivation to learn is internal

This can be summed up in the simple idea, adults will only learn when they are seeking solutions to problems they have. I posted this a couple of years ago on Knowles.

What Hatch is addressing can be seen as HCP and the healthcare system not helping patients identify the problems they are having and demonstrating solutions to those problems. The idea is to aid patients in becoming motivated through learning and self-identifying problems they may not realize they or others with similar conditions are having. As much as HCP want to be educators (Hatch’s top down idea) HCP must focus on learning what the needs/problems patients are having specific to              their conditions. Personalized healthcare focused on the problems/needs/motivations of a patient is as important as matching a patient genetics to treatment, it needs to become personalized learning for the patient. You know the whole give him a fish teach her to fish thing.

Virtual Patient: Real Learning for Medical Students in Primary Care

Salminen, Zary, et. al submitted an original paper in JMIR “Virtual Patients (VP) in Primary Care: Developing a Reusable Model That Fosters Reflective Practice and Clinical Reasoning“. 

The authors were looking to create a virtual patient model for the primary care setting that would drive reflective practice and clinical reasoning. The virtual patient they sought to create included embedded process skills applicable to the primary care setting. 

Using virtual patients in medical education is not new. It has been used in all stages of a medical students learning to teach communication skills, patient focus, clinical reasoning, and reflective learning. What the authors note as lacking are reports on how to design and use VP within the primary care setting. 

The model the authors build they embedded ways to promote meaningful learning such as reflection, clinical reason, and in depth subject knowledge. This was accomplished with open-ended questions and free-text answers as well video clips. Students worked these cases independently without help from teachers it is self-directed and at their own pace. 

What struck me about this study is how they authors approached this. They built the VP around adult learning and not how can we cram as much knowledge as possible into a student and how do we do this around primary care. Using adult learning theory primarily Kolb and Schon’s reflection and change they found unsurprisingly students responded  positively and were able to apply new knowledge to their understanding of medicine. 

It would be interesting to see how a VP can be build around current epatients and their behavior as active learners and participants in their healthcare. Can a VP be used to demonstrate how to engage patients better and improve communications skills of those physicians well past medical school. 

Swarming Toward Knowledge in the Era of Evidence Based Medicine

Swarm-Based Medicine
Putora and Oldenburg publishing in JMIR.org present a fascinating and insightful review of how medical decisions are made in the “absence of evidence-bsed guidelines”. Using crowd sourcing or “swarm-based medicine physicians add a further source of information to evidence based medicine or eminence-based medicine.

There are many concerns about the limitations of evidence-based medicine, but there are two obvious ones. First, evidence-based medicine is based on available data. However, relevant data is not available for all relevant issues. Also, trials with a negative outcome are underrepresented in medical literature, rendering the evidence base biased and the view of reality skewed

What struck me as I was reading this paper was how much of what the authors present fits with the work of Malcolm Knowles and the subsequent work of Dr. Hank Slotnick. Knowles is considered the father of adult learning theory and practice. His primary idea was that adults will learn only when faced with a problem.

Knowles characterized adult learning as follows:

  1. Self-concept: As a person matures his self concept moves from one of being a dependent personality toward one of being a self-directed human being
  2. Experience: As a person matures he accumulates a growing reservoir of experience that becomes an increasing resource for learning.
  3. Readiness to learn. As a person matures his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles.
  4. Orientation to learning. As a person matures his time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem centredness.
  5. Motivation to learn: As a person matures the motivation to learn is internal

In the early 1999 Dr. Slotnick took wrote the following paper “How Doctors Learn: Physicians’ Self-directed Learning Episodes” which identified four stages of physician learning. They are:

Stage 0: scanning for potential problems

Stage 1: deciding whether to take on the problem

Stage 2: learning the required skill and knowledge

Stage 3: gaining experience

Two other considerations to this paper are small group learning theory where small groups tend to be more productive and effective at sharing and learning. And the idea of communities of practice where groups coalesced around the need to solve a problem. Once the problem was resolved the community went away. 

I believe the authors have identified that the Internet is driving the more productive and efficient application of the above theories and principles. It will be interesting to see if educators will begin to put new Internet based learning principles in place as more work such as yours is provided. 

I wrote to the authors and received the following response which is important:

Maybe if physicians become more aware of their swarm behavior it will influence how they approach learning. Possibly by integrating distribution/cooperation into these learning stages, currently they are focused around a single point of view. 

It is also fascinating to reflect on how small learning groups behave, when their boundaries by which they are defined disappear through constant interaction with the outside..
Take a look at the article it is important and points to a tend.