Domain of Competence: Practice-Based Learning and

ImprovementAnn E. Burke, MD; Bradley Benson, MD; Robert Englander, MD, MPH;Carol Carraccio, MD, MA; Patricia J. Hicks, MD, MHPE

From the Wright State University Boonshoft School of Medicine, Dayton, Ohio (Dr Burke); Department of Internal Medicine and Pediatrics,University of Minnesota Medical School, Minneapolis, Minn (Dr Benson); Association of American Medical Colleges, Washington, DC (DrEnglander); Competency-Based Assessment, The American Board of Pediatrics, Chapel Hill, NC (Dr Carraccio); and Department ofPediatrics, Childrens Hospital of Philadelphia, Philadelphia, Pa (Dr Hicks)The views expressed in this report are those of the authors and do not necessarily represent those of the Accreditation Council for GraduateMedical Education, the American Board of Pediatrics, the Association of Pediatric Program Directors, or the Academic Pediatric Association.The authors declare that they have no conflict of interest.Publication of this article was supported by the American Board of Pediatrics Foundation and the Association of Pediatric Program Directors.Address correspondence to Ann E. Burke, MD, Wright State University Boonshoft School of Medicine, One Children’s Plaza, DaytonChildren’s Hospital, Department of Pediatrics, Dayton, OH 45404 (e-mail: ann.burke@wright.edu).

KEYWORDS: pediatrics; residency; graduate medical education;undergraduate medical education; competency based education;practice based learning and improvement

ACADEMIC PEDIATRICS 2014;14:S38–S54

THE DOMAIN FOR self-directed learning and/or self-improvement as a physician is complex, involving 10 com-petencies focused on learning and improvement aroundabilities that allow a pediatrician to become a more master-ful doctor. The notions of internal motivation, desire toimprove and do better, and self-determination are all atwork in this domain. Internal motivation is hard to directlyobserve but can be inferred by longitudinal observation ofbehaviors. Malcolm Knowles1 first established the defini-tion of self-directed learning as a process in “which individ-uals take the initiative (with or without the help of others) indiagnosing their learning needs, formulating goals, identi-fying human and material resources for learning, choosingand implementing appropriate learning strategies, and eval-uating learning outcomes.” Attributes of a self-directed,lifelong learner include

one who exhibits initiative, independence, and persis-tence in learning; one who accepts responsibility forhis or her own learning and views problems as chal-

ACADEMIC PEDIATRICSCopyright ª 2014 by American Board of Pediatrics andAccreditation Council for Graduate Medical Association

S38

lenges; one who is capable of self-discipline and has ahigh degree of curiosity; one who has a strong desireto learn or change and is self-confident; one who isable to use basic study skills, organize his or her timeand set an appropriate pace for learning, and to developa plan for completing work; one who enjoys learningand has a tendency to be goal-oriented.2

Practice-based learning and improvement lends itself towatching a learner over time, allowing for inference, overmany episodes in which they demonstrate self-directed be-haviors. These themes thread throughout the followingmilestones.

REFERENCES

1. Knowles M. Self Directed Learning: A Guide for Learners and Teach-

ers. New York, NY: Associated Press; 1975.

2. Guglielmino LM. Development of the Self Directed Learning Readi-

ness Scale [dissertation]. Athens, Ga: University of Georgia; 1977.

Competency 1. Identify strengths, deficiencies, and limits in one’s knowledge and expertise

Patricia Hicks, MD, MHPE

BACKGROUND: Residents’ ability to identify theirstrengths, deficiencies, and limits in knowledge and exper-tise are related to their ability to self-assess and their abilityto use feedback from external assessment. An earlylearner’s awareness of his performance against an internalor external standard is often prompted by consequencesor rewards within the educational system or other regulato-ry or institutional oversight. The motivation and vigilantawareness of this performance becomes more intrinsic

with development. Guidance and external measures ofknowledge and expertise will most likely continue to pro-vide oversight (eg, maintenance of certification processes),although such oversight cannot determine the learningneeds for individual physicians.1

The stimulus for identifying strengths, deficiencies, andlimits in knowledge and expertise, when intrinsically moti-vated, usually arises from recognition of a gap in knowl-edge or skills identified in a particular clinical context.

Volume 14, Number 2SMarch–April 2014

Table 1. Facilitator Guide for Interactive Case-Based Discussion*

Generic Question Specific Thinking Skills Induced

What are the strengths and weaknesses of X? Analysis/ability to draw inferencesWhy is X happening?What are the implications of X?

What is the difference between X and Y? Compare–contrast; differentiate

Explain why X (Explain how X)? AnalysisWhat is the nature of X?

What would happen if X? Prediction/hypothesizing

What is a new example of X? ApplicationHow could Y be used to (achieve or result in) X?

What is X analogous to? Identification and creation of analogies and metaphors

What do we already know about X? Activation of prior knowledge

How does X affect X? Analysis of relationships (cause–effect)

*Modified from King.8 The interactive case-based discussion is one in which residents’ discussion could be observed, scored, and critiqued

on the basis of the level and nature of inquiry as it relates to their level of knowledge, skills, and attitudes.Questioning by the learner reveals the

current state of knowledge as well as that learner’s ability to identify gaps in knowledge and understanding.

Table 2. A guide for the continuum of learner identification of level of knowledge, skills, and attitudes (KSA), including deficiencies and areas

of strength. Achievement of this competency involves multiple areas of development and is therefore contingent upon achievement across all

of these elements. Scoring this item is complex andmay not reflect a synchronous progression along each of the elements, but rather a slower

rate of achievement in some with a more rapid compensatory progression in others.

KSA indicates knowledge, skills, and attitude.

*Includes deficiencies and areas of strength. Achievement of this competency involves multiple areas of development and is therefore

contingent upon achievement across all of these elements. Scoring this item is complex and may not reflect a synchronous progression along

each of the elements, but rather a slower rate of achievement in some with a more rapid compensatory progression in others.

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S39

S40 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

The learner may be prompted to identify a gap when apatient’s problem is novel or outside of the scope of previ-ous experience; when tension or dissatisfaction aboutperceived competence occurs during a learning activity;or when he is unable to meet the expectation (from selfor others) to manage, teach, or elaborate about specificknowledge and skills and their application.

The resident’s ability to make “sense of the world,” inthe words of John Dewey,2 is often influenced by doubt,uncertainty, or perceived difficulty. Kolb3 suggests thatreflection on previous experiences helps us formulatehypothetical questions (prompted from recognition andresponse to perceived gaps in knowledge, skills, and atti-tudes [KSA]) and engage in active experimentation (eg,reading, applying various new strategies/approaches),both of which inform our learning going forward. Sch€on4

describes a process whereby one reflects on a clinical issueeither during or outside of the immediate clinical situation.Such reflection, which embraces uncertainty, conflict, andambiguity, pushes the physician toward seeking newknowledge or skills in an attempt to understand and thenincorporate this new learning into practice. It is not onlythe identification of the presence of tension but also theidentification of specific deficiencies or limitations inKSA that is critical.

Resource-seeking and question-asking skills are criticalto identifying and specifically sorting out strengths versusdeficiencies. The formation of questions enables a learnerto more clearly determine the difference between their cur-rent versus ideal knowledge and skills, to develop a visionof the ideal competencies and behaviors, and to reflect onthe forces encouraging and impeding change.5 Developingquestioning skills was identified as a critical first step. Thenature, clarity, and specificity of the questions, as well asthe resources sought to answer those questions, are criticalto the learner’s identification of knowledge and expertise.Gorman6 and Ely et al7 report on the large number andthe type of questions raised by those in practice. The natureand quality of the questions spanned a wide range, and theresource seeking for answers varied as well. King8 de-signed a tool to help students in large-group learning ses-sions develop questions by introducing them to a genericstem template (Tables 1 and 2).

DEVELOPMENTAL MILESTONES:

� Acknowledges external assessment of performance, butunderstanding of performance level is limited to the overall grade;there is little understanding of how the performance measurerelates in a meaningful way to specific abilities of KSA.Example: During a semiannual review, a learner is unable to

describe in any specific terms how he has performed when asked

to do so by his mentor. In response, the mentor reviews and

interprets the learner’s evaluations and then asks the learner to

reflect on the discussion. The learner repeats the language used

and recites the overall score/grade without interpretation of

further meaning or inference regarding the reported performance

assessment.

�Seeks to address gaps in KSA, citing that purpose is to respond touncertainty, discomfort, or tension in completing clinical duties.Assesses his own performance on the basis of successful orunsuccessful performance of the task at hand withoutappreciation for how well it is done and whether there is need forimprovement.Example: The learner seeks external assessment of performance

as ability “to do” or “not able to do” with little understanding of

what the assessment means. “Are these orders written

correctly?” “Did I do that correctly?” Seeks feedback approval on

whether KSA were “right” or “wrong.” Does not seek “how” or

“why” as part of request for feedback to assist identification

of KSA.

� Seeks to address gaps in KSA, citing response to uncertainty,discomfort, or tension in completing clinical duties as prompt.Actively questions and applies knowledge in developing a rationalefor care plans or in teaching activities.Example: “Why would we use this antibiotic for this condition?” or

“The patient has underlying condition X. Does that alter therapy y

for this patient?” or “I think we should order study w for this patient,

because sometimes this disease presents with underlying

condition Z.”

� Seeks to address gaps in KSA, citing anticipation or contemplationof potential clinical problems as prompt; the learner self-identifiesgaps in KSA through external input and reflection that assessescurrent KSA versus understanding of underlying basic science orpathophysiologic principles. Evidence of this stage can bedetermined by the advanced nature and level of questioning orresource seeking.Example: In caring for a patient with an illness not previously

encountered, this practitioner says, “I have experience taking care

of patients with this acute illness, but have never had a patient with

both this acute illness and this particular underlying condition. I

wonder if the chronic condition might alter the clinical course in this

patient?”

� Seeks to increase level of KSA, citing the desire to expand KSAbeyond what is needed for the current or immediately anticipatedclinical care of a patient. Uses elaborate questions to further exploregaps and strengths in KSA.Example: In caring for a patient, a practitioner becomes aware of a

gap in KSA, and in response (with or without consultation from a

mentor) seeks to learn more. A PICO-formatted question (P ¼Patient, I ¼ Intervention, C ¼ Comparison, O ¼ Outcome) is

constructed, followed by a process of identification of learning

needed.

REFERENCES

1. Green JS, Leist JC. Determining needs from the perspective of institu-

tions of organizations providing care. In: Davis D, Barnes BE, Fox R,

eds. The Continuing Professional Development of Physicians. Chi-

cago, Ill: AMA Press; 2003:97–111.

2. Dewey J, ed. How We Think? Boston, Mass: DC Health and Co; 1933.

3. Kolb D. Experiential Learning as the Science of Learning and Devel-

opment. Englewood Cliffs, NJ: Prentice Hall; 1984.

4. Sch€on D. Educating the Reflective Practitioner. San Francisco, Calif:

Jossey-Bass Publishers; 1987.

5. Fox RD, Mazmanian PE, Putnam RW. Changing and Learning in the

Lives of Physicians. New York, NY: Praeger Publishers; 1989.

6. Gorman PN. Can primary care physicians’ questions be answered

using the medical journal literature? J Med Libr Assoc. 1994;82:

140–146.

7. Ely JW, Osheroff JA, Ebell MS, et al. Analysis of questions asked by

family doctors regarding patient care. BMJ. 1999;319:358–361.

8. King A. Designing the instructional process to enhance critical

thinking across the curriculum. Teach Psychol. 1995;22:13–17.

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S41

Competency 2. Set learning and improvement goals

Patricia Hicks, MD, MHPE

BACKGROUND: Malcolm Knowles1 first established thefollowing definition of self-directed learning (SDL) thatguided work in this area: a process in “which individualstake the initiative (with orwithout the help of others) in diag-nosing their learning needs, formulating goals, identifyinghuman andmaterial resources for learning, choosing and im-plementing appropriate learning strategies, and evaluatinglearning outcomes.” As our understanding of SDL hasgrown, more recent definitions, such as that of Hammondand Collins,2 reflect the complexity of the phenomenon:

Aprocess inwhich learners take the initiative,with the sup-port and collaboration of others, for increasing self and so-cial awareness; critically analyzing and reflecting on theirsituations, diagnosing their learning needs with specificreference to competencies they have helped identify;formulating socially and personally relevant learninggoals, identifying human and material resources forlearning, choosingand implementing appropriate learningstrategies; and reflecting on and evaluating their learning.

The very nature of practice, especially for residents, in-volves addressing a variety of patient problems. As such,the development of short- and long-term goals may requirethe collection and analysis of information from several sour-ces. However, as a result of the task-centered, hypothetico-deductive* world experienced by the learner, the need tosolve individual patient problemsmayonly give rise to goalsthat are short term in nature. Often, learners need assistancein envisioning longer-term or more elaborate goals withinwhich shorter-term goals can be more systematically devel-oped and staged. One method of developing these goals isthrough the use of learning partners, as described byCharlesCampion-Smith,3 in which physicianswork in pairs to assistone another with the development of goals and with othersteps in the SDLprocess, including evaluating achievement.This kind of partnership works well beyond the setting ofgoals and extends into actual learning. The work of activitytheorists and of Vygotsky4 suggest that one physician in thepair inevitably leads, pulls, or pushes the other to a newperspective or greater understanding. This dynamic canlead to accelerated learning and change that may not beachieved by the individual alone.

In setting learning and improvement goals, physiciansrespond most commonly to perceived needs. Discovery of

*Hypothetico-deductive reasoning is a scientific method whereby test-

able hypotheses are gathered from an existing set (fromwithin the individ-

ual’s knowledge or from an available source); then one systematically tries

to falsify those hypotheses. This approach presumes to have an established

start point where a finite number of possible hypotheses or working

models lead to an outcome, and one goes about eliminating those possibil-

ities. This method is in contrast to an approach whereby one accumulates

favorable evidence to induce a theory, to construct a hypothesis, or to

assemble a critical mass of evidence to support an evolving or existing the-

ory or hypothesis.

these needs can be stimulated by several situations, includingcaring for a particular patient, discoveringa surprise that chal-lenges usual practice, anticipating a needed skill generatedthrough reading, engaging in conversation with a colleague,overhearing a conversation among other physicians, orattending a formal educational session. Other prompts tolearner self-directedness that contribute to initiating learningand improvement goals include motivation, self-regulation,and learner self-efficacy. For many, however, these self-directed needs may be unknown or subjectively understood,and they may not reflect actual learning needs.5 This under-scores the importance of structures, such as learning partners,supervisors/teachers, and oversight institutions, in the devel-opment and implementation of and accountability withlearning and improvement goals.

DEVELOPMENTAL MILESTONES:

�Constructs learning goals at the “how-to” level, promptedby theacuteneeds of patients with well-defined conditions. The goal is to find theanswer to the “then this” in the “if this–then this” logic statement.Example:DrMoore is admitting a patientwith asthmaand realizes the

need to write admission orders. With Internet and supervisory

resident-based resources available, he asks his supervisor for the

asthma protocol, then proceeds to copy the orders line by line.When

questioned on rounds about knowledge gaps, he cites the goal as

using a protocol to address gaps.

� Constructs learning goals to address gaps in knowledge, skills, andattitudes (KSA) identified in the context of care delivery. These goalsmay be reinforced by other team members, such as through peerquestioning or request for teaching. Goals extend beyond the “howto” KSA to include understanding of the pathophysiologic basis orunderlying basic science principles.Example: Dr Kim is on call and is in the process of admitting a

patient with an acute exacerbation of asthma, brought on after

playing with a friend’s cat. As Dr Kim is writing the orders, a third-

year medical student asks about the steroid dose. Dr Kim does not

simply answer the student’s question with the protocol’s written

dosage but begins to think about why steroids are used in asthma.

This interaction prompts Dr Kim to look for materials that describe

the inflammatory changes in the airways in patients with asthma.

� Constructs learning goals to address gaps in KSA needed to care forhypothetical patients who vary from the index case or who, uponreflection, were previously encountered.Example:DrSmith seeks further knowledgeandsets out to retrieve a

systematic review of steroids in asthma and establishes a new goal

to learn about their use in allergy-triggered events versus other

triggers.

�Constructs learning goals focused on readying self to teach and leadothers. Goals have a more elaborate contextual framework, withcontent areas linked by common pathophysiologic grounding orother relationships, such as common clinical symptoms or signs.Example: As Dr Doe reads about the management of asthma and

the role of anti-inflammatory medications in the management of

disease exacerbations, related questions arise, with new goals,

such as: 1) Why are anti-inflammatory medications used for

prevention? 2) How does the mechanism of action of a steroid

medication differ from a mast cell stabilizer medication? 3) How

ought one ideally manage a currently asymptomatic child who was

going to visit his grandmother (who has several cats) for the

weekend if that child had cat allergy–induced asthma

exacerbations?

S42 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

� Identifies multiple learning goals as a habit. Content areas are basedon ongoing reflection and continuous effort to expand KSA. Citesdesire to develop others through teaching and leading withimproved KSA, including teaching others how to set learning goals.(Relates to professionalism milestone of learning for the sake ofbecoming the best physician, ready for best practice.)Example: After seeing several patients in a continuity clinic with

asthma on the problem list, Dr Jones realizes that many of the

patients have had frequent exacerbations that suggest difficulty in

their ability to manage their asthma. He sets new goals to learn

about motivational interviewing and seeks the help of a master in

achieving this goal.

Table 3. Matching Educational Methods to Objectives*

Educational Method

Cognitive;

Knowledge

Cognitive;

Problem Solving

Readings Y ?Lecture Y ?Discussion Y YProblem-solving exercises Y YProgrammed learning Y YLearning projects Y YRole models N ?Demonstration ? ?Real-life experiences ? YSimulated experiences ? YAudio or video review of learner ? NBehavioral/environmental

interventionsN N

Y indicates recommended for instruction; N, not recommended; and ?

with other methods.

*Modified from Kern et al.2

REFERENCES

1. Knowles MS. Self-Directed Learning: A Guide for Learners and

Teachers. New York, NY: Associated Press; 1975.

2. Hammond M, Collins R. Self-Directed Learning:Critical Practice.

New York, NY: Nichols/GP Publishing; 1991.

3. Campion-Smith C. Interprofessional Learning in Primary Care: The

Dorset Seedcorn Project. Dublin, UK: World Conference of Family

Doctors; 1998.

4. Vygotsky LS.Mind in Society: The Development of Higher Psycholog-

ical Processes. Cambridge, Mass: Harvard University Press; 1978.

5. Norman GR. The adult learner: a mythical species. Acad Med. 1999;

74:886–889.

Competency 3. Identify and perform appropriate learning activities to guide personal andprofessional development

Patricia Hicks, MD, MHPE

BACKGROUND: The process of selecting learning resourcesrequires an understanding of how one is able to take in newinformation, sometimes referred to as a learning style orpreference1; the type of learning content (knowledge,skills, reasoning, behavioral or attitudinal change, orgrowth) and what instructional methods best address thattype of learning content (Table 3)2; awareness of availableresources3; skills in seeking those resources3; and consid-eration of the appropriateness of the selected resource toachieve the intended outcome.

Understanding of one’s preference of instructionalmethods and the effectiveness and efficiency of thosemethods to achieve growth in knowledge, skills, and atti-tudes (KSA) often require a significant amount of discussionand consultation, although experience with various strate-gies through a trial-and-error approach often leads to prefer-ences (albeit perhaps inefficient or suboptimally effectiveones). Applying learner preferences to identify resources,the availability and accessibility of the resources, and theireffectiveness and efficiency with respect to learners’ goalsare important aspects in identifying what types of experi-

enceswill contribute to learning. Learners should be encour-aged to select from both formal and informal educationalresources and may need assistance to consider and weighpossible learning alternatives, such as clinical rotations orother clinical training experiences, formal courses, home-study modules, study groups, and online study.The type of instructional method chosen for teaching

various types of KSA is critical.2 Acquiring competencein the psychomotor aspects of procedural skills is optimallydone using simulation,where demonstration and then delib-erate practice4 can take place. Using simulation to expandone’s content knowledge would not be as effective as otherinstructional strategies. The curriculum presented to alearner will often provide resources for core KSA, butassessment of this competency aims to determine whether,when given a choice, the learner chooses a resource thatuses an instructional approach that has been proven to effec-tively produce the desired outcome or achievement2 or doesshe choose an ineffective resource (Table 3).Also, the learner must identify outcome measures for

those learning activities. Indeed, one of the most difficult

Affective;

Attitudinal

Psychomotor;

Skills or Competence

Psychomotor; Behavioral

or Performance

? ? N? ? NY ? N? N ?N ? N? ? ?Y ? Y? Y YY Y YY Y ?N Y ?? ? Y

, may be appropriate in some cases but best if used in combination

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S43

tasks is selecting appropriate signposts of progress andvalid indicators that goals are being met. It is importantfor each learner to participate in the selection of outcomesthat are relevant and valid indicators of change. Further,where the desired goal may be long term, learners maywish to identify indicators along the way. Mazmanianand Mazmanian5 emphasize the importance of a writtencommitment to a specifically stated change or the levelof dedication to learning specific KSA in bringing aboutthe change or the new learning.

Norman6 challenged the notion that adult learners couldself-direct their learning and suggested that the constructionof goals and the selection of resources to reach those goalsmay be limited by self-awareness, knowledge and the abilityto direct learning. Eva7 claimed that external guidancewouldalways be required for unfamiliar areas of practice, “thusreducing thevalidity of the rhetoric aroundnurturing learnersto be self-directed.” Schmidt8 put forward similar argumentsfor his claim that the importance of self-directed learningskills in professional practice had been overemphasized.Seeking resources for guidelines, policy, or more systematicapproaches to learning, development, and change, however,does benefit the learner. The dissemination of lessons learnedassists the learner further when that individual chooses toteach others and shares resources.9

DEVELOPMENTAL MILESTONES:

� Engages in learning activities on the basis of readily available resourcesor curricular materials, irrespective of learning style, preferences,appropriateness of activity, or any outcome measures.Example:After realizing aneed tobetter understandwhatmedications

should be used in the management of a clinic patient with moderate

asthma, the learner asks a peer who is workingwith him in clinic rather

than pursuing the references suggested by his clinic preceptor.

� Engages in learning activities assigned by others; prescribedinstructional materials are provided by others.Example: A learner reads cases assigned for primary care in

advance of coming to a scheduled clinic sessionwhere a discussion

of the cases is to take place. After the session, the resident wonders

about the case and its relevance to overall learning. The case is part

of a core curriculum with learning goals and objectives. Later, in

clinic, a patient presents with a problem similar to last week’s case

discussion, and the learner is able to go back to that case to glean

further information on how to manage the patient.

� Seeks learning resources on the basis of analysis of learning needsassessment and subsequent constructed goals, with considerationof the nature of learning content and method.Example:Having failed at intubation in the delivery room, the learner

goes back to the simulation lab to receive further training on

intubation with the manikin (and does not simply reread the

Neonatal Resuscitation Protocol10).

� Selects learning activities on the basis of instructional methods thatare known tobe effective in advancement of knowledge.Knowledgeapplication, and skills or behaviors. Learning takes place throughcollaborative interaction with experts. Learning activities sought areones that allow for constant course correction and interactivesharing of alternative perspectives.Example:A learner is planning an advocacy workshop for parents of

children with complex medical needs to improve their skills with

managing medical devices. In the process of preparing for this

workshop, he discovers that there is an in-service for parents of

hospitalized patients in how to care for devices and participates in

this learning activity. Through this in-service, he identifies written

resources, models useful for demonstrations, and video-recorded

illustrations of anticipated complications with device use. He

chooses to conduct a practice rehearsal with some families in the

inpatient setting, with course correction from the hospital’s nurse-

educator.

� Selects learning activities, shares activities of value with others, andseeks input from others regarding additional learning activities.Example: Seeks to expand the types of devices discussed in the

workshop and looks to the work published by the Institute of

Medicine Committee on Safe Medical Devices for Children.11

Decides to pursue resources (experts in the field) to see if it would

be possible to learn how to provide the instructional materials,

plans, and workshops to parents throughout the state.

REFERENCES

1. Kolb D. Experiential Learning as the Science of Learning and Devel-

opment. Englewood Cliffs, NJ: Prentice Hall; 1984.

2. Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum Develop-

ment for Medical Education: A Six Step Approach. Baltimore, Md:

Johns Hopkins University Press; 1998.

3. Accreditation Council for Graduate Med Education. ACGME compe-

tencies. Practice-based learning and improvement. Available at: http://

www.acgme.org/acgmeweb/Portals/0/PDFs/commonguide/IVA5c_

EducationalProgram_ACGMECompetencies_PBLI_Explanation.pdf.

Accessed September 13, 2013.

4. Ericsson KA, Prietula MJ, Cokely ET. The making of an expert. Harv

Bus Rev. 2007;85:114–121.

5. Mazmanian PE, Mazmanian P. Commitment to change: theoretical

foundations, methods and outcomes. J Contin Educ Health Prof.

1999;19:200–207.

6. Norman GR. The adult learner: a mythical species. Acad Med. 1999;

74:886–889.

7. Eva KW. On the generality of specificity.Med Educ. 2003;37:587–588.

8. Schmidt H. Assumptions underlying self-directed learning may be

false. Med Educ. 2000;34:243–245.

9. Kimball HR, Young PR. Educational resource sharing and collabora-

tive training in family practice and internal medicine. A statement

from the American Boards of Internal Medicine and Family Practice.

JAMA. 1995;293:320–322.

10. Kattwinkel J, ed. Neonatal Resuscitation Textbook. 5th ed. Elk Grove

Village, Ill: American Academy of Pediatrics; American Heart Asso-

ciation; 2006.

11. FieldMJ, Tilson H, eds. Safe Medical Devices for Children. Washing-

ton, DC: National Academies Press; 2005:480.

Competency 4. Systematically analyze practice using quality improvement methods andimplement changes with the goal of practice improvement

Robert Englander, MD, MPH

BACKGROUND: The ability to systematically analyze practiceusing quality improvement methodology, and to implement

change as a result, is embedded in a variety of knowledge,skills, and attitudes (KSA). There are 3 important areas of

S44 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

content knowledge: the standards of medical care (eg, evi-dence-based pathways and guidelines),1 changemanagementprinciples, and quality improvement methodology. From askills standpoint, one needs to be able to apply this knowledgeto one’s practice beginning at the individual patient level andextending to populations of patients and, in the most expertsense, to the system of care.2 From an attitudinal standpoint,one needs to develop the habit of reflective practice and toembrace change.

To some extent, the system in which one finds oneselfwill be a determinant of the capacity to master the requisiteKSA for this competency. The knowledge content may bedetermined by the local quality improvement methodologyused (eg, rapid cycle change using the Plan–Do–Study–Actmethodology), and the application of that knowledge willdepend to some extent on the degree to which the systemis predisposed to change. Additionally, the traditional med-ical model with a focus on episodic care and individualphysician autonomy is often at odds with the precepts ofquality improvement and population and systems manage-ment.3 Hockey and Marshall4 perhaps articulate this ten-sion best: “A defining role of the doctor of the future—and a justification for their intensive training, status, andremuneration—should be their willingness to balance theinherent tensions between providing all possible care forindividuals and designing systems which make clinicallyeffective care available to whole populations.” Of partic-ular importance is an understanding of these precepts inthe context of this competency and their implications forresident education. Almost 2 decades ago, Ashton1 under-scored the importance of integrating residents into the hos-pital’s and practice’s quality improvement programs. Withrare exceptions, we have made little advancement in thisarea in the interim.

Finally, the ability to analyze practice and improvegenerally requires a team approach. An example might bethe pediatric practice that is trying to increase its compli-ance with known evidence-based care of patients withasthma by ensuring the documentation of a home manage-ment plan of care. The documentation of the asthma planmay initially be viewed as the sole purview of the doctor;however, on more in-depth analysis, improvement mayrequire a front office practice to ensure the form is placedappropriately in all asthmatic patient charts, a nursing prac-tice to review interval symptoms andmedication adherencewith the patient before the doctor’s arrival, a patient careassistant’s follow-up call, and a case manager’s interfacewith the third-party payer for special but appropriateprescriptions or for home visiting nurse services to ensureadherence.

Despite the potential system and team limitations toan individual’s development in this competency, a clearpathway can be outlined, understanding that the degreeto which one progresses may be limited by the practiceenvironment in which one finds oneself. Individuals inthe earliest stage of development in this competencyhave a surface-learning approach. They accumulate unre-lated facts and treat parts separately, show no evidence ofreflection on purpose or strategy (ie, lack reflective prac-

tice), and find an answer to a problem without graspingthe underlying issues or principles (ie, lack insight).5 Inaddition, individuals in this stage tend to become defensivewhen others provide them with evidence of their opportu-nities for improvement. For example, the pediatric inten-sive care unit director in this stage of development, facedwith a high rate of catheter-associated bloodstream infec-tions, might focus on why his patient population differsfrom the norm and argue each individual case.As one continues along the developmental stages, one

demonstrates increasing ability to reflect. Initially, thisreflection is focused on individual patient encounters or ex-periences that allow improvement without much relianceon the system or team. These physicians might have littleknowledge of or experience with improvement methodolo-gies, and their improvements will thus be limited to the in-dividual patient encounter and based to some extent onintuition. In addition, individuals in this stage tend to bedependent on external sources to delineate their perfor-mance and guide their priorities for improvement.The more advanced physician in this competency both

understands and applies the precepts of quality improve-ment and does so both for individuals and populations ofpatients. However, the improvement is focused on andlimited to one’s own practice patients. These individualsdemonstrate a deep-learning approach by relating newideas to their previous knowledge and experience and byfocusing on the critical aspects of a professional situation.5

They are also continuously evaluating their practice perfor-mance for opportunities for improvement and thus are ableto prioritize their change management.At the most advanced stage of development, the physi-

cian has developed the habit of reflection on practice andcontinuous performance review and has applied those re-flections using sound improvement methodology to hisown patient population. He seeks to influence improve-ment at the broader population level, such as through pub-lication of results that can be generalized. An examplemight be the endocrinologist who develops a system of dia-betic management that is far superior to the national bench-marks in outcomes (eg, hemoglobin A1c) and disseminatesthat change through publications and presentations at na-tional meetings. The reader is also referred to anotherexcellent example of mastery of this competency demon-strated in a series of practices working with payers in theMinneapolis/St Paul health care system to improve a pop-ulation’s overall care.6

DEVELOPMENTAL MILESTONES:

� Unable to gain insight from encounters as a result of a lack ofreflection on practice. Does not understand the principles of qualityimprovement methodology or change management. Is defensivewhen faced with data on performance improvement opportunitieswithin one’s practice.

� Able to gain insight from reflection on individual patient encounters,but potential improvements limited by lack of systematicimprovement strategies and team approach. Dependent onexternal prompts to define improvement opportunities at thepopulation level.

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S45

� Able to gain insight for improvement opportunities from reflection onboth individual patients and populations. Grasps improvementmethodologies enough to apply to populations. Still reliant onexternal prompts to inform and prioritize improvement opportunitiesat the population level.

� Able to use both individual encounters and population data to driveimprovement using improvement methodology. Analyzes one’sown data on a continuous basis, without reliance on externalforces, to prioritize improvement efforts. Uses that analysis in aniterative process for improvement. Able to lead a team inimprovement.

� In addition to demonstrating continuous improvement activities andutilizing quality improvement methodologies, thinks and actssystemically to try to use one’s own successes to benefit otherpractices, systems, or populations. Open to analysis that at timesrequires course correction to optimize improvement.

REFERENCES

1. Ashton CM. “Invisible doctors”: making a case for involving medical

residents in hospital quality improvement programs. Acad Med. 1993;

68:823–824.

2. Moore LG, Wasson JH. Improving efficiency, quality and the doctor–

patient relationship. Fam Pract Manag. 2007;20–24.

3. Sutherland K, Dawson S. Power and quality improvement in the new

NHS: the roles of doctors and managers. Qual Health Care. 1998;

7(suppl):S16–S23.

4. Hockey PM, Marshall MN. Doctors and quality improvement. J R Soc

Med. 2009;102:173–176.

5. Burge SM.Undergraduatemedical curricula: are students being trained

to meet future service needs? Clin Med. 2003;3:243–246.

6. Reinertsen JL. Collaborating outside the box: when employers and pro-

viders take on environmental barriers to guideline implementation. J

Qual Improv. 1995;21:612–618.

Competency 5. Incorporate formative evaluation feedback into daily practice

Carol Carraccio, MD, MA

BACKGROUND: Feedback is the control of a system by re-inserting into the system the results of its performance. Ifthese results are merely used as numerical data for criti-cism of the systems and its regulation, we have the simplefeedback of the control engineer. If, however, the informa-tion that proceeds backward from the performance is ableto change the general method and pattern of the perfor-mance, we have a process which may very well be calledlearning.1

It is important to be precise about what feedback is andwhat it means. In his classic article, Ende2 tells us that feed-back occurs “when a student or house officer is offeredinsight into what he or she actually did as well as the con-sequences of his or her actions.” He highlights the differ-ence between feedback and assessment. The former isspecific to individual aspects of a learner’s performance,formative (ie, intended to help form the learner into amore successful professional), neutral, and not intendedto make commentary on overall performance. In contrast,the latter is more generalized, summative, and intendedto provide commentary on a learner’s overall performance.He also makes the critical point that “observations are thecurrency of feedback,”2 with direct observation being theessential backbone of optimal feedback.

In the search for the development of responses to feed-back, a seemingly sentinel article emerges from the highereducation literature. In this article, Nichol andMacfarlane-Dick3 remind us that it is important to ensure that feedback,per se, has occurred before we think about the appropriate-ness of a learner’s response. The feedback message mustnot only be appropriately articulated but then “decodedand translated into action”3 by the learner. At the sametime, they point out that feedback messages are complexand not readily translatable into action without some dis-cussion that leads to further understanding and processing.The authors also stress the point that although we tend tothink of feedback as being transmitted from external sour-

ces, internal feedback is critical. Focusing only on externaltransmission ignores the role that beliefs and motivationplay in the response to feedback. This reference to internaland external sources calls into play the work of Forsythe4

as it bears on identity development. In the earliest stagesof identity development, there exists only one point ofview for the individual—his own. In the next stage, hecan understand the viewpoints of others, but they are trans-lated and internalized in a way that serves his own needsand interests. When applied to feedback, this suggeststhat the translation of the feedback may be different fromthe intended message and likely will not lead to the desiredbehavioral changes intended by the person giving the feed-back. As one progresses along the continuum of identitydevelopment, one becomes able to see multiple perspec-tives simultaneously. At advanced levels of development,one is primarily motivated by personal expectations ratherthan the expectations of others. In other words, individualsat these advanced levels are proactive in seeking feedbackbecause they want to improve rather than being reactive inresponding to feedback because others would like them toimprove.Interestingly, Nichol and Macfarlane-Dick3 reinforce

Forsythe’s4 construct of identity development using amodel of response to feedback that is built on the founda-tion of self-regulation. The construct of self-regulation orself-monitoring has recently emerged in the medical edu-cation literature and provides some insight into an elementof self-assessment that holds greater promise of accuracythan self-assessment. Archer5 defines self-monitoring as“the ability to respond to situations shaped by one’s owncapability at that moment in that set of circumstances,rather than being governed by an overall perception of abil-ity.” Although everyone is generally poor at self-assess-ment in the global sense of predicting how well we willdo something, Eva and Regehr6 suggest that we are muchbetter at knowing our limitations when we are actively

S46 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

engaged in an activity at point of care. In essence, this typeof reflection in action, or self-monitoring, is our response tointernal feedback. For example, a learner may not be ableto accurately assess his ability to resuscitate a newbornwith perinatal asphyxia, but when called to the deliveryroom, he knows when he is in over his head and appropri-ately requests help to avoid compromising patient care.

It is important for a teacher to discern the level of identitydevelopment of a learner in order to package feedback in away that can best help lead to desired behavioral change.Other major influences that have been reported to affectresponse to external sources of feedback are its source,duration, and monitoring. Feedback from a supervisor oradministrator (as opposed to participation in a researchintervention), providing feedback over the long term (yearsas opposed to months), and ongoing monitoring (asopposed to recording results of a short-term intervention)have been shown to enhance response to feedback.7 Rele-vance, by linking feedback to goal setting, in conjunctionwith facilitated support, are other key ingredients inenhancing receptivity and bringing about positive change.5

Sargeant et al8 summarize their findings from a number ofstudies involving feedback. In addition to many of the influ-ences noted above, they also highlight that physicians aremore likely to respond to feedback from patients than col-leagues. The authors also emphasize that feedback that isinconsistent with one’s self-perceptions may evoke strongemotional responses that inhibit assimilation and behavioralchange. The recommended antidote to this emotionalresponse is reflection, particularly facilitated orguided reflec-tion. This is an important take-home message for educators.

DEVELOPMENTAL MILESTONES:

�Has difficulty considering others’ points of viewwhen they differ fromhis own, leading to defensiveness and inability to receive feedbackand/or avoidance of feedback; demonstrates a limitedincorporation of formative feedback into daily practice.

� Is dependent on external sources of feedback for improvement; isbeginning to acknowledge other points of view, but reinterpretsfeedback in a way that serves his own need for praise orconsequence avoidance, rather than informing a personal quest forimprovement; little to no behavioral change occurs in response tofeedback (eg, listens to feedback but takes away only thosemessages he wants to hear).

� Understands others’ points of view and changes behavior toimprove specific deficiencies that are noted by others (eg,understands that the perceptions of others are important evenwhen those perceptions are different from his own, such as when anurse interprets a response as abrupt when it was not intended tobe, causing him to examine what prompted this perception).

� Internal sources of feedback allow for insight into limitations andengagement in self-regulation; improves daily practice on the basisof both external formative feedback and internal insights (eg, is ableto point out what went well and what did not go well in a givenencounter, and makes positive changes in behavior as a result).

� Demonstrates professional maturity and deep emotionalcommitment that lead to deliberate practice and result incontinuous reflection, self-regulation, and internal feedback thatlead to ongoing improvement beyond a focus solely on deficiencies.

REFERENCES

1. Weiner N. The Human Use of Human Beings in Cybernetics and Soci-

ety. Boston, Mass: Houghton Mifflin Co; 1950:71.

2. Ende J. Feedback in clinical medical education. JAMA. 1983;250:

777–781.

3. Nichol DJ, Macfarlane-Dick D. Formative assessment and self-regu-

lated learning: a model and seven principles for good feedback prac-

tice. Stud Higher Educ. 2006;31:199–218.

4. Forsythe GB. Identity development in professional education. Acad

Med. 2005;80:S112–S117.

5. Archer J. State of the science in health professional education: effective

feedback. Med Educ. 2010;44:101–108.

6. Eva KW, Regehr G. Self-assessment in the health professions: a refor-

mulation and research agenda. Acad Med. 2005;80:S46–S54.

7. Veloski J, Boex JR, Grasberger MJ, et al. Systematic review of the liter-

ature on assessment, feedback and physicians clinical performance.

BEME Guide 7. Med Teach. 2006;28:117–128.

8. Sargeant J, Mann K, van der Vleuten C, et al. Directed self-assessment:

practice and feedback within a social context. J Contin Educ Health

Prof. 2008;28:47–54.

Competency 6. Locate, appraise, and assimilate evidence from scientific studies related totheir patients’ health problems

Ann Burke, MD

BACKGROUND: Evidenced-based medicine (EBM) isdefined as “the conscientious, explicit and judicious useof current best evidence in making decisions about thecare of individual patients.”1 Given the increasing amountof medical information and knowledge, physicians need todevelop systematic strategies to deal with and manage allof the information regarding their patients. In this develop-mental milestone, we will examine the knowledge, skills,and attitudes (KSA) required for the actual steps involvedin EBM, recognizing that in reality one cannot practiceEBM without the ability to set learning and improvementgoals or the motivation to be a lifelong learner.2

The classic steps that need to be repetitively accom-plished to practice EBM include the following.3–6

CONVERT THE NEED FOR INFORMATION INTO AN ANSWERABLE

QUESTION

This may also be described as formulating a clinicalquestion typically in PICO format, addressing the prob-lem/population (P), intervention (I), comparison (C),and outcome (O). Again, to recognize the critical impor-tance of this learning activity, one must have the requisitemotivation and maturity to set learning and improvementgoals.

SEARCH FOR BEST EVIDENCE TO FIND ANSWERS

Residents need to learn, via practice, what to look for,how to look for it, and where to search.1

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S47

CRITICALLY APPRAISE THE EVIDENCE FOR ITS VALIDITY,APPLICABILITY, AND IMPACT

This step involves asking and answering the followingquestions: What are the results? Are the results valid?Are the results relevant? Critical appraisal involves a com-plex series of cognitive tasks that include processing in-formation in research studies, weighing evidence, andbalancing the multifactorial information about the individ-ual patient’s unique situation to arrive at an evidence-informed medical decision. Critical appraisal is the art ofEBM; it is far more complex than following steps to takecare of generic patients (or to participate in so-called cook-book medicine).

INTEGRATE FINDINGS WITH CLINICAL JUDGMENT

Taking into account patient values and clinical circum-stances. To accomplish this step, one must simultaneouslymove along the developmental continuum in other areas ofpractice-based learning and improvement and other com-petencies.

BRING ABOUT CHANGE

Onemust be able to apply the evidence and then evaluateone’s effectiveness and efficiency, seeking ways toimprove both.

The following attributes and descriptions characterizelearners in various stages of development.

EARLY DEVELOPMENT OF KSA FOR EVIDENCE-BASEDPRACTICE

Characterized by a learner who needs help identi-fying personal knowledge gaps and converting knowl-edge gaps into an answerable clinical question. Thenovice asks others with more perceived experience foranswers to general questions. Initial forays into litera-ture searching involve use of general search engines(eg, Google) with excessive return of low-level evi-dence. In the searching process, there is an inabilityto filter searches to limit returns to high-quality studieswith optimal methodology. A novice or early learnerhas minimal ability to critically appraise an article.Application of the study findings to a patient is ofteninappropriate.

INTERMEDIATE DEVELOPMENT OF KSA FOR EVIDENCE-BASEDPRACTICE

Characterized by a learner who is able to identify knowl-edge gaps in the course of patient care. The learner is addi-tionally able to convert knowledge gaps into answerableclinical questions. Learners in this developmental stagebegin to ask more specific questions (foreground ques-tions) in areas where content knowledge is more advanced.They can successfully perform a literature search usingMedline databases and retrieve high-quality evidence toanswer clinical questions. They are also able to utilizemethodologic filters to increase the quality and decrease

the quantity of the citations returned. Critical appraisal isimproving using standardized tools that are specific toeach study design. The learner may begin to apply the find-ings of studies of populations to individual patients, takinginto account the patient’s own values and resources and theclinical context.

ADVANCED DEVELOPMENT OF KSA FOR EVIDENCE-BASEDPRACTICE

Characterized by demonstration of ongoing,habitual asking and answering of clinical questionsfrom one’s patient care as part of an ongoingcommitment to continuous professional development.The learner demonstrates effective and efficient searchstrategies for complex clinical questions utilizing avariety of medical databases and best-evidence re-sources. Additionally, the learner is able to improviseto find clinical evidence when initial search strategiesfail. This stage is characterized by advanced skill incritical appraisal of clinical studies of multiple meth-odologies (eg, randomized controlled trial, cohortstudy, systematic review, cost–benefit analysis).Masterfully able to integrate evidence gained fromliterature searching into complex clinical decisionmaking; consistently takes the patients’ values and re-sources, as well as the clinical context, into consider-ation. Seeks out and enjoys the difficult clinicalquestions to continually push and expand capabilitiesin evidence-based practice.7

A number of guidebooks contain information on howto teach critical appraisal skills and attitudes via thesystematic approach that is called EBM.2,3 In termsof teaching and learning EBM, it is important to notethat the literature informs us that the outcomes ofteaching EBM are improved if there is practice- orcase-based learning and time is set aside for thislearning.8,9 Thus, introducing EBM to undergraduatesin their curriculum is a favored technique to allowlearners to actively practice EBM in a clinical settingat a point when large time constraints are not presentand to allow one to methodically respond to the steeplearning curve. In a systematic review of the effective-ness of EBM and critical-appraisal teaching starting atthe postgraduate level, Coomarasamy and Khan10

concluded that the studies showed a significantimprovement in knowledge but not in attitude, skills,or behavior during residency. Most sources agree thatto become proficient in EBM, a learner must utilizeinteractive and clinically integrated activities in addi-tion to interactive classroom-based activities and mustbegin this process early in their education.4,11,12 There-fore, a sound strategy is to teach and practice EBM inundergraduate medical education, with subsequentpractice of EBM on a regular basis to improve KSAas a resident. EBM skill development truly spans thecontinuum of medical education.13

S48 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

DEVELOPMENTAL MILESTONES:

� Explains basic principles of EBM, but relevance is limited (eg, by littleclinical exposure).Example: The senior resident asks each member of the inpatient

team to answer a clinical question that he raised during rounds and

to be prepared to discuss it the next morning. The learner goes to a

more senior colleague for help because he cannot work through a

case or article using the critical appraisal approach, mainly because

of a lack of clinical context to work from.

� Recognizes the importance of using current information to care forpatients and responds to external prompts to do so. Able to formulatequestions with significant effort and time; online search efficiency isminimal (eg, may require multiple search strategies). Knows how toread and interpret the literature but requires guidance for application.Example: In response to a clinical question raised during rounds and

the senior resident’s request that everyone answer the question, the

learner is able, with help, to frame the question in a Population–

Intervention–Comparison–Outcome (PICO) format. Hehas searching

capability, but the search and the steps of analyzing and applying the

evidence are time intensive, so he is not prepared to discuss his

findings on rounds the next morning.

� Identifies knowledge gaps as learning opportunities. Makes an effortto ask answerable questions on a regular basis and is becomingincreasingly able to do so. Understands varying levels of evidenceand can utilize advanced searchmethods. Able to critically appraisea topic by analyzing the major outcome but may need guidance inunderstanding the subtleties of the evidence. Begins to seek andapply evidence when needed, not just when assigned to do so.Example: In response to the clinical question raised during rounds,

the learner develops an answerable clinical question in PICO format

and efficiently searches for best evidence. Volunteers to present on

rounds the next day and demonstrates effective analytic skills and

the ability to apply his findings to the current patient. Has a bit of

difficulty interpreting and applying some of the secondary

outcomes. In the context of this discussion, another question is

raised, which he volunteers to research and answer.

� Formulates answerable questions regularly, seemingly as a result ofdemonstrated increasing self-motivation to learn more. Incorporatesuse of clinical evidence in rounds and teaches fellow learners. Quitecapable of advanced searching. Able to critically appraise topics anddoes so regularly. Shares findings with others to try to improve theirabilities. Practices EBM because of the benefit to the patient and thedesire to learn more rather than in response to external prompts.Example: In response to the clinical question raised during

rounds, presents a second question that he has already researched

in a PICO format as well as a critique of the evidence and its

applicability to the current patient. He was motivated to be proactive

by his interest in learning as well as the needs of his patient. He

shares his tactics with teammembers by teaching them the steps he

engaged in to learn and apply this information.

� Teaches critical appraisal of topics to others. Strives for change atthe organizational level as dictated by best current information. Ableto easily formulate answerable clinical questions, and does so withthe majority of patients as a habit. Able to effectively and efficientlysearch and access the literature. Seen by others as a role model forpracticing EBM.Example: Is an EBM practitioner, as observed by conversations

during rounds, whom others try to emulate. He enjoys teaching

colleagues how to become EBM practitioners by role modeling. He

helps team members develop and refine their skills using his

expertise to make a difficult task practical and doable.

REFERENCES

1. Sackett DL, Rosenberg WM, Gray JA, et al. Evidenced based medi-

cine: what it is and what it isn’t. BMJ. 1996;312:71–72.

2. KnowlesMS,Downie CM,Basford P. Teaching andAssessing in Clin-

ical Practice. London, UK: University of Greenwich; 1998:22–38.

3. Sackett DL, Straus SE, Richardson WS, et al. Evidenced-Based Med-

icine: How to Practice and Teach EBM. 2nd ed. New York, NY:

Churchill Livingstone; 2000.

4. Guyatt G, Rennie D. User’s Guide to the Medical Literature: A

Manual for Evidenced-Based Clinical Practice. Chicago, Ill: AMA

Press; 2002.

5. Das K, Malick S, Khan K. Tips for teaching evidence-based medicine

in a clinical setting: lessons from adult learning theory. Part 1. J R Soc

Med. 2008;101:493–500.

6. Malick S, Das K, Khan K. Tips for teaching evidence-based medicine

in a clinical setting: lessons from adult learning theory. Part 2. J R Soc

Med. 2008;101:536–543.

7. Bereiter C, ScardamaliaM. Surpassing Ourselves: An Inquiry into the

Nature of Expertise. Chicago, Ill: Open Court; 1993.

8. CoomarasamyA, Taylor R, Khan K. A systematic review of postgrad-

uate teaching in evidence-based medicine and critical appraisal.Med

Teach. 2003;25:77–81.

9. Khan K, Coomarasamy A. A hierarchy of effective teaching and

learning to acquire competence in evidenced-based medicine. BMC

Med Educ. 2006;6:59.

10. Coomarasamy A, Khan K. What’s the evidence that postgraduate

teaching in evidenced-based medicine changes anything? A system-

atic review. BMJ. 2004;329:1017–1019.

11. Pitkala K, Mantyranta T, Strandberg TE, et al. Evidence-based med-

icine—how to teach critical scientific thinking to medical undergrad-

uates. Med Teach. 2000;22:22–26.

12. Norman GR, Shannon SI, Marrin ML. Learning in practice: the need

for needs assessment in continuing medical education. BMJ. 2004;

328:99–101.

13. Kersten HB, Thompson ED, Frohna JG. The use of evidence-based

medicine in pediatrics: past, present, and future. Curr Opin Pediatr.

2008;20:326–331.

Competency 7. Use information technology to optimize learning and care delivery

Bradley Benson, MD

BACKGROUND: Developing and maintaining competencein the use of information technology is vital in the modernpractice of medicine, and its role will continue to expandand evolve.1–7 The field has changed dramatically in a rela-tively short period of time as a result of several factors,which include the exponential growth in clinically relevantinformation, nearly universal access to this informationenabled by the World Wide Web, commoditized technol-ogy that brings access to the classroom and to the pointof care (eg, netbooks, workstations on wheels, smart-

phones, iPads), and the widespread adoption of electronichealth records8 (EHRs) and learner portfolios.9

THE EVOLVING FOCUS ON INFORMATION TECHNOLOGY: Inthe late 1990s, the Association of American Medical Col-leges10 issued Report II of the Medical School ObjectivesProject, in which they noted that, “Physicians will haveto possess the knowledge, skills, and attitudes (KSA)required to be competent in medical informatics if theywish to incorporate into their practices systematic ap-proaches for promoting and maintaining the health of

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S49

defined populations.” The report outlined learning objec-tives specifically related to medical informatics necessaryto fulfill the following 5 roles of the physician: lifelonglearner, clinician, educator/communicator, researcher,and manager. As with many of the other milestones, signif-icant overlap exists between medical informatics compe-tence and attainment of competence in the otherdomains. Here we will focus on the specific KSA relatedto the use of information technology that enhance one’sability to fulfill each of the above roles.

Of note, since the introduction of the learning objec-tives for the roles related to information technologylisted above, medical schools have made major invest-ments in information technology, with nearly ubiquitouscomputer and internet access, creation of virtual cam-puses, and widespread adoption of technology-enhancedlearning.11 A follow-up study 8 years after the initialreport, however, showed that only a handful of schoolstaught and assessed medical informatics objectives thatrequired interaction with patient health information,12

underscoring the importance of intentional focus onthese objectives at this time. The importance of theseobjectives has been emphasized by the AccreditationCouncil for Graduate Medical Education and the Amer-ican Board of Pediatrics, with increasing requirementsfor the use of EHRs in training, and the use of informa-tion technology for data collection and reporting of qual-ity improvement projects as part of maintenance ofcertification, respectively.THE DEVELOPMENTAL PROGRESSION OF INFORMATION

TECHNOLOGY CAPABILITY: The technology acceptancemodel (TAM), as originally described by Davis,13 is a crit-ical tool in understanding the progression of capabilitywith respect to the use of information technology. Thismodel identifies the drivers of user acceptance of technol-ogy and notes 2 major factors that impact usage behavior:perceived ease of use and perceived usefulness. Of these 2factors, perceived ease of use is the more important and hasthe greater impact on behavior. Understanding the determi-nants of perceived ease of use is vital, as it is an initial hur-dle that early learners must overcome for acceptance,adoption, and use of a system.13,14 The work of Venka-tesh15 in this area has built upon the TAM by integrating4 factors that determine early perceptions of the ease ofuse of a new system:� Internal control—Characterized by one’s own sense of

computer savvy or self-efficacy.� External control—Perception of support/facilitators in

the environment to help with use of the new system(ie, availability of 24/7 tech support during Epic (Ver-ona, WI) implementation).

� Intrinsic motivation—Characterized by “computer play-fulness” or one’s intrinsic enjoyment in interacting witha new gadget or information system.

� Emotion—Characterized by computer anxiety and anegative affective reaction to computer use.In applying this model to early learners in a medical

setting, it is clear that the factors above impact individ-uals in a unique way, directly affecting their likelihood

of embracing use of the new technology and ultimatelytheir behavior. As individuals gain personal experiencewith the technology, however, these factors attenuateon the basis of their objective experience with the sys-tem and modify their perception of the system’s easeof use. Anyone with experience in implementing anEHR system has seen the variation in user acceptanceand evolution over time. This literature is of greatimportance to information technology developers andconsumers alike, as many investments in informationtechnology have failed to yield the expected improve-ments in productivity or outcomes because of a lack ofuser acceptance.In proposing developmental milestone levels related to

the use of information technology, we rely heavily on thescholarly work cited above as well as the DreyfusModel16,17 and the work on expertise by Bereiter andScardemalia.18 Although it is widely perceived that thenew generation of physicians in training are technologi-cally savvy, there will always be variations in computerself-efficacy, playfulness, and anxiety that directly affecteach learner’s progression and level of skill. Learners onthe anxious and less confident end of the technology spec-trum must gain enough objective experience and haveenough success with the information technology to over-come their initial misgivings if they are ever to progress.Early attempts at literature searching or accessing a pa-tient’s medical record may be overwhelming as a resultof the number of information retrieval tools available,the volume of information retrieved, and minimal abilityto filter or prioritize. As skills develop, learners are betterable to choose which database to search to best answer aspecific question, to know where to look in an EHR for aspecific piece of patient information, and to develop arepertoire of experience in filling their own knowledgegaps.Competent users of information technology have an

emotional investment in the outcome; they feel goodwhen they are able to successfully answer a clinicalquestion using information technology resources andfeel bad when they cannot. Similarly, if an EHR queryor use of a new standardized best practice order set fora patient admitted with bronchiolitis goes well, thensatisfaction results; if errors or difficulties occur, thendissatisfaction results. This emotional investment is evi-dence of an internal motivation that will help the compe-tent learner continually improve and progress to a higherskill level. In these later stages, efficiencies develop, andthe use of new information technology is often intuitiveand enjoyable. Troubleshooting and problem solving arethe responses to any failed attempts to use informationtechnology for learning or patient care. As use of theEHR for individual patient care is streamlined, thegained time can be reinvested in use of the EHR for ac-tivities such as population health initiatives. At the high-est stages of professional achievement, one contributesto the continuous improvement of current informationtechnology systems and the development of new onesto improve patient care and learning.

S50 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

DEVELOPMENTAL MILESTONES:

� Utilizes information technology only with mandatory assignmentsand direct help. Does not demonstrate discernment in choosingbetween multiple available databases for clinical query and doesnot filter or prioritize the information retrieved, which results in toomuch information, much of which is not useful. Requires directsupervision in use of EHR. Challenges in the use of informationtechnology may lead to resistance to adopting new technologies.

� Utilizes information technology for patient care assignments orlearning. Identifies and chooses among several availabledatabases, search engines, or other appropriate tools, resulting in amanageable volume of information, most of which is relevant to theclinical question. Basic use of an EHR is improving, as evidenced bygreater efficacy and efficiency in performing needed tasks.Beginning to identify shortcuts to getting to the right informationquickly, such as use of filters. Also beginning to avoid shortcuts thatlead one astray of the correct information or that perpetuateincorrect information in the EHR. Demonstrates a willingness to trynew technologies.

� Retrieves (from EHR, databases, and other resources), manages,and utilizes biomedical information efficiently in solving problemsand making decisions that are relevant to the care of patients andfor ongoing learning.

� Consistently utilizes familiar information technology resources andseeks new ones to answer clinical questions and remedyknowledge gaps identified in the course of patient care; utilizes theEHR platform to improve the care not only for individual patients butpopulations of patients; and utilizes evidence-based (actuarial)decision support tools to continually supplement clinicalexperience.

� In addition to the behaviors illustrated in the milestone immediatelyabove, engages in the continuous improvement of current systemsand the development and implementation of new informationtechnology innovations for patient care and professional learning.

REFERENCES

1. Srinivasan M, Keenan C, Yager J. Visualizing the future: tech-

nology competency development in clinical medicine, and im-

plications for medical education. Acad Psychiatry. 2006;30(6):

480–490.

2. Meehl PE. Clinical Versus Statistical Prediction. Minneapolis, Minn:

University of Minnesota Press; 1954.

3. Dawes R, Faust D, Meehl PE. Clinical versus actuarial judgement.

Science. 1989;243:1668–1674.

4. EricssonKA. Deliberate practice and the acquisition andmaintenance

of expert performance in medicine and related domains. Acad Med.

2004;79:S70–S81.

5. Barnes B. Creating the practice-learning environment: using informa-

tion technology to support a new model of continuing medical educa-

tion. Acad Med. 1998;73:278–281.

6. Blumenthal J, Mays B, Weinfeld J, et al. Defining and assessing med-

ical informatics competencies. Med Ref Serv Q. 2005;24:95–102.

7. Gray K, Sim J. Factors in the development of clinical informatics

competence in early career health sciences professionals in Australia:

a qualitative study. Adv Health Sci Educ. 2011;16:31–46.

8. Duncan J, Evens R. Using information to optimize medical outcomes.

JAMA. 2009;301:2383–2385.

9. Carraccio C, Englander R. Evaluating competence using a portfolio: a

literature review and Web-based application to the ACGME compe-

tencies. Teach Learn Med. 2004;16:381–387.

10. Association of American Medical Colleges. Contemporary issues in

medicine—medical informatics and population health: Report II of

the Medical School Objectives Project. Acad Med. 1999;74:130–141.

11. Ward J, Gordon J, Field M, Lehmann H. Communication and infor-

mation technology in medical education. Lancet. 2001;357:792–796.

12. McGowan JJ, Passiment M, Hoffman HM. Educating medical stu-

dents as competent users of health information technologies: the

MSOP data. Stud Health Technol Inform. 2007;129:1414–1418.

13. Davis FD. Perceived usefulness, perceived ease of use, and user

acceptance of information technology. MIS Q. 1989;13:319–339.

14. Davis FD, Bagozzi RP, Warshaw PR. User acceptance of computer

technology: a comparison of two theoretical models. Manage Sci.

1989;35:982–1002.

15. Venkatesh V. Determinants of perceived ease of use: integrating con-

trol, intrinsic motivation, and emotion into the technology acceptance

model. Inf Syst Res. 2000;11:342–365.

16. Dreyfus HL, Dreyfus SE. Mind Over Machine. New York, NY: Free

Press; 1988.

17. Carraccio C, Benson B, Nixon J, Derstine P. From the educational

bench to the clinical bedside: translating the Dreyfus Developmental

Model to the learning of clinical skills. Acad Med. 2008;83:761–767.

18. Bereiter C, ScardemaliaM. SurpassingOurselves: An Inquiry Into the

Nature and Implications of Expertise. Chicago, Ill: Open Court Pub-

lishing Company; 1993.

Competency 8. Develop the necessary skills to be an effective teacher

Ann Burke, MD

BACKGROUND: What is an effective teacher, and whatcharacteristics do these teachers possess? In this compe-tency, a number of knowledge, skills, and attitudes(KSA) form the conceptual framework for effective teach-ing. It is important to note that the definition of effectivemay be difficult to quantify because much of the literatureon this ability is based on perceptions and not on learneroutcome measures. The KSAmay progress at similar rates,or some elements may lag behind while others progress.For example, someone may be very learner-centered andadaptable, but she may feel inadequate as a result of insuf-ficient content knowledge. A few overarching themes thatprogress through the developmental process toward a goodor effective teacher are teacher-centered versus learner-centered approaches; fixed approach with teaching

methods versus adaptability; and inadequacy versus confi-dence. These are each discussed in turn.TEACHER-CENTERED VERSUS LEARNER-CENTERED AP-

PROACHES: A learner-centered teacher asks learnersabout their needs and aims to align the teaching methodand content with the specific learner at hand. This conceptalso includes creating a learning climate that facilitatesoptimal learning. For example, a teacher who showsenthusiasm and empathy for learners, does not interruptpresentations on rounds, and encourages questions islearner-centered. In contrast, a teacher-centered approachis one that focuses on the teacher’s needs. Little to noeffort is put into assessing what the learner may need.This approach is typically symptomatic of a lack ofinsight and of feelings of inadequacy about the

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S51

knowledge and skills for teaching, which results inwanting to stay in a prepared and rehearsed mode ofteaching to remain safe. Alternatively, it may be becauseof a lack of interest and enthusiasm for the task of teach-ing. An example of this concept is a new teacher who pre-pares every bit of detailed medical information about atopic so as not to appear to be lacking in knowledge;however, his talk may be overwhelming, too expansive,and unfocused, and thus unhelpful to the learners.Another example is a professor who is lecturing about atopic with no attempt to make it relevant to the particularaudience. He may even speak for 10 minutes over time,again focusing on his desire to talk about everything heprepared rather than on the learner’s desire to have theirtime respected.FIXED APPROACH VERSUS ADAPTABILITY: Adaptability re-fers to the willingness of teachers to modify the form andcontent of instruction, their ability to change style on thebasis of subtle cues from learners, and their capability tonot be fixed or limited in style. This theme includes thecreativity of the teacher. Inflexible teachers do not changeaccording to the situation. For example, a fixed or inflex-ible teacher would likely not shorten rounds to allow a resi-dent to get to clinic because “that is how they always runrounds.” Another example is a resident who continueslecturing students long after a number of them have dozedoff.INADEQUACY VERSUS CONFIDENCE: Confidence in teach-ing may stem from a number of factors, including positivereinforcement, enthusiasm, experience, and self-identity asa teacher. Some of these thoughts about self-efficacy andself-perception may be inaccurate or overvalued. That isto say, although confidence is a characteristic of effectiveteaching, one who is confident alone may not be an effec-tive teacher. Often, early-stage teachers may be so focusedon their own knowledge content and learning needs thatthey may feel inadequate and unsafe teaching others. Amaster teacher, on the other hand, probably has appropriateconfidence in an insightful way and a positive self-image asa good teacher.

In one study, the following 3 key themes seem to emergewhen faculty and residents are attempting to characterizeand describe good teaching attributes: enthusiasm forteaching (current and future), learner centeredness, andself-knowledge about teaching.1 In this qualitative study,the intervention group of residents received 13 more hoursof resident-as-teacher development compared to the con-trol group. The study took place in a university medicalcenter with primary care residents. Qualitatively analyzedresident interviews identified the above themes and foundthat their self-perceptions of their teaching roles persistedfor over 1 year after the intervention. Other descriptionsof effective teaching and precepting include similarthemes, such as respect for learners, positive rolemodeling, and demonstrable patient care skills.2,3 Inanother study, the authors developed a validated facultypeer evaluation on teaching skills, which resulted in thefollowing list of behaviors of effective teachers4:

� Establishes a safe and positive learning environment andlearner involvement.

� Leads teaching sessions.� Communicates goals of teaching and is learner centered.� Uses appropriate methods and materials.� Primes the learner by asking for commitment, plan, and

responses (in a learner-centered manner).� Gives feedback to learners.� Encourages learners to continue their learning.In a study by Beckman,4 peer-to-peer evaluations

occurred between faculty attendings on a general internalmedicine hospitalist service. Many of the categories uti-lized were adapted from the Stanford Faculty DevelopmentProgram-26 (SFDP-26),5which is a validated questionnairefor students and residents to use in evaluating attendings.However, it is important to recognize that students maynot have views completely similar to faculty and/or maynot value the same teacher attributes that faculty value.6

Being a teacher is generally perceived as a favorablequality or skill for a physician to have; however, it doesrequire time and effort. The quality of teaching can becomesubject to contextual circumstances and can advance orregress through the milestones. In general, the progressionthrough the milestones follows the 3 overarching conceptsdetailed above.

DEVELOPMENTAL MILESTONES:

�Demonstrates a completely teacher-centered approach; focused onwhat needs to be taught rather than the learning needs of thestudents. Barriers to effective teaching may include lack of contentknowledge and/or lack of teaching skills and repertoires. Difficultyadapting because of need for preparation and scripted teaching.Early learner in medical content. This may be expressed as feelingsof insecurity with teaching and low confidence level.

� Demonstrates an approach that is weighted toward teacher-centric. Isable to identify a good teacher, but lacks insight to be able to articulatethe discrete qualities that contribute to this skill. Adapting to others’learningneeds is challenging, so there is little deviation fromanypresetplans. Does not see learners as barriers/nuisance, but may demon-strate ambivalence with them. Expresses feelings of inadequacy/insecurity as a result of limited teaching repertoire and experience.

� Exhibits some learner-centered teaching behaviors, but remainsmostly teacher centered. Able to identify a few of the discretequalities of effective teaching behaviors. Teaching methods andrepertoire are expanding and therefore less limited and moreadaptable. Communicates a self-identity as one who likes to teach.Gaining confidence in teaching abilities, demonstrated asincreasing interactions with learners and enthusiasm for assistingthem in learning.

� Exhibits a learner-centered approach to teaching. Assesses learnerneeds and incorporates them to advance learners. Eager andenthusiastic to teach. Shows enriched insight and understanding ofsome teaching concepts and is able to adapt and modify teachingto meet unforeseen learner needs in most situations. Developslearner-centered goals. More relaxed and confident with teaching,with obvious enjoyment in this role.

� Consistently demonstrates a learner-centered approach to teaching.Understands and seeks new information regarding teaching andlearning. Identified by others as a dedicated teacher on the basis ofthe time and energy committed to teaching, which is part of the coreof her self-image. Ensures that both intended learning goals as wellas newly defined goals of learners are achieved. Confidence inteaching skills allows for creative and adaptive teaching abilities.

S52 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

REFERENCES

1. Morrison E, Shapiro J, Harthill M. Resident doctors’ understanding of

their roles as clinical teachers. Med Educ. 2005;39:137–144.

2. Irby DM, Ramsey PG, Gillmore GM, Schaad D. Characteristics of

effective clinical teachers of ambulatory care medicine. Acad Med.

1991;66:54–55.

3. Lie D, Boker J, Dow E, et al. Attributes of effective community precep-

tors for pre-clerkship medical students.Med Teach. 2009;31:251–259.

4. Beckman T. Evaluating an instrument for the peer review of inpatient

teaching. Med Teach. 2003;25:131–135.

5. Skeff KM. Enhancing teaching effectiveness and vitality in the ambu-

latory setting. J Gen Intern Med. 1988;3:26–33.

6. Busari JO, Scherpbier A, van der Vleuten C, et al. The per-

ceptions of attending doctors of the role of residents as teach-

ers of undergraduate clinical students. Med Educ. 2003;37:

241–247.

Competency 9. Participate in the education of patients, families, students, residents, and otherhealth professionals

Ann Burke, MD

BACKGROUND: This competency will focus on patient andfamily education; other competencies focus on students,residents, and other health professionals.

The concepts of educating oneself and educatingothers share many of the same features and abilities.Another competency, “Develop the necessary skills tobe an effective teacher,” outlines 3 themes that establishthe context within which effective teaching is consid-ered. These 3 overarching themes are teacher-centeredversus learner-centered approaches, fixed approachversus adaptability, and inadequacy versus confidence.That competency is perhaps more pertinent for medicalteaching. This competency will focus on the additionalaspects of exemplary educational interactions with pa-tients and families.

Patient education involves a complex set of skills and ca-pabilities, which span a number of competency domainsdescribed elsewhere in the Milestones document and re-quires the following:� Knowledge about the particular disease process and/or

health promotion concepts that pertain to each individ-ual patient (medical knowledge).

� The ability to navigate the medical interview andencounter (patient care).

� The capability to counsel patients and families (patientcare).

� The capabilities that allow physicians to communicateeffectively with others across a broad range of socioeco-nomic and cultural backgrounds (interpersonal andcommunication skills).One difference between patient education and edu-

cation of trainees and peers involves the dimensionof professional satisfaction associated with demon-strating behaviors consistent with effective patient ed-ucation. Consider that the profession recognizes andacknowledges medical trainee teaching with awards.Additionally, teaching medical students, residents,and peers is documented and valued in curriculumvitae. Physicians rarely receive formal recognitionfor ongoing, habitual, effective patient and family ed-ucation; however, the professional and personal satis-faction gained is noteworthy. Thus, patient and familyeducation seems to be rooted in altruism and mindfulpractice.1

One author considers the term patient education to be“unfortunate” because it suggests passive reception of in-formation by the patient. In reality, the interplay of physi-cian and patient/family is optimized when it is dynamicand interactive and consists of 2-way discussion.2 Patientswho take an active role in their own care have better out-comes in terms of quality of life, health, and satisfaction.3

Physicians demonstrating capabilities at the more expertend of the developmental spectrum in this milestone arecompletely aware of and incorporate this concept into prac-tice.The medical encounter with patients/families serves 3

functions, as outlined in the competency “Interviewingpatients/families about the particulars of the medical con-dition for which they seek care, with specific attention tobehavioral, psychosocial, environmental, and family-unitcorrelates of disease.” The 3 functions are to gather bio-logical and psychological information, to respond to theemotions of patients/families, and to educate patients/families to ensure desired outcomes.4–6 The content areasof the last 2 functions, which are pertinent here, are as fol-lows2:

RESPOND TO THE EMOTIONS OF PATIENTS/FAMILIES

� Define the nature of the relationship.� Communicate professional expertise.� Communicate interest and empathy.� Recognize potential relationship barriers in the doctor–

patient relationship.� Gain insight into the patient’s perspective.

EDUCATE PATIENTS/FAMILIES AND SUBSEQUENTLY

IMPLEMENT TREATMENT PLANS

� Negotiate and resolve any issues or conflict betweenphysician and patient.

� Communicate about the diagnostic and prognostic char-acteristics of the diagnosis.

� Negotiate and recommend appropriate diagnostic proce-dures and treatment.

� Negotiate and recommend appropriate preventativemeasures, such as lifestyle change.

� Enhance coping skills and ability by enhancing under-standing of health issues.

ACADEMIC PEDIATRICS PRACTICE-BASED LEARNING AND IMPROVEMENT S53

Additionally, some authors suggest that the medicalencounter can be divided into the following 4 distinct func-tional components4,6–8: 1) data gathering, 2) building rela-tionships, 3) patient education and counseling, and 4)activating and partnering. Activating implies the functionthat “facilitates the expression of patients’ expectations,preferences, and perspectives so that they may more mean-ingfully participate in treatment and management decisionmaking.”4,6 Phrases such as “What do you think is goingon?,” “I understand you don’t like that,” “Does that seemto be clear to you?,” which express concern for patientopinion and check for understanding, are components ofactivating and partnering behaviors. In the progression ofthese milestones, the partnering aspect of patient educationwill be emphasized. Further, there is an instrument toassess these interactions: the Roter Interaction AnalysisSystem, or RAIS.4,6,7 This instrument can be used to assessresident progression through this milestone.

To clarify and further define the terms activationand partnering, a few points need to be emphasized.There can be a wide spectrum of effectiveness of inter-actions with patients from ineffective to effective inmodifying behavior. Progressing through these mile-stones, one would become increasingly focused on theoutcomes. A physician who habitually asks herself,“How can I modify behavior and have good patientcare outcomes from partnering with and activating thechild and family?,” is far advanced beyond the doctorwho simply goes through the motions of patient educa-tion without deliberate thought. Some evidence aboutpatient encounters to consider when using a frameworkof enhancing change and promoting complianceinclude2,3,6:� Few patients change behavior with unilateral physician

communication of information/lecturing-type educa-tion.

� Rates of patient compliance and behavior change in-crease with the simple addition of patient handouts/liter-ature.

� Health literacy, or the level of understanding by readingand/or listening that a patient possesses, needs to betaken into account.

ADDITIONAL CONSIDERATIONS

What characteristics aid a physician in becoming onewho participates in education of patients and families?One study looked at characteristics, capacities, and skillsthat distinguish physicians as good at patient communica-tion/education.9 In this particular study, the term capacitiesreferred to physicians’ values, beliefs, and intentions con-cerning the patient. Thus, capacities encompass constructssuch as compassion, empathy, respect, honesty, and integ-rity. In this study, the patients were adolescents, and thecomponents that appeared to be necessary to educate andcommunicate with this group of pediatric patients wereempathy, nonjudgmental attitude, and self-reflection.9 In

pediatrics, physicians must utilize the principles outlinedabove, but they must also modify and be flexible with re-gard to various ages, developmental stages, and literacylevels.

DEVELOPMENTAL MILESTONES:

� Adheres to a scripted type of patient education and counseling(which may be due to knowledge and experience) that may notmeet the needs of the patient. Doctor-centered interaction.

� Demonstrates a somewhat flexible type of patient education andcounseling (possibly as a result of closing some of the gaps in hisknowledge and experience base), allowing him to educate patientsand families in a way that begins to meet their needs. Educationvaries between doctor centered and patient centered, dependingon the circumstances and the family dynamics. Responsive topatient’s educational needs. Checking for patient understandingwhen triggered by patient questioning.

� Demonstrates a solid breadth of both knowledge and experience;modifies teaching to meet the needs of the individual patient.Educational efforts are typically patient centered, and the learner isable to modify strategies to adapt to complex patientcharacteristics. Checks for patient understanding when cuessuggest confusion.

� Demonstrates a broad knowledge base and significant experiencewith a variety of disease processes and patient characteristics.Facilitates the participation of patients in all discussions about theirhealth. Is flexible with strategies of educating patients. Patient-centeredness is clearly a priority and a conscious effort.Consistently checks for patient understanding. Empowers andmotivates patients.

� Engages in behaviors described in level immediately above and alsocontinually demonstrates patient-centeredness. Seamlessly,skillfully, and comfortably educates and interacts with patients in away that satisfies the patients. Exceptional ability to motivate andempower patients to make healthy changes and choices. Does notleave the patient encounter without knowing that the patientunderstands the counseling.

REFERENCES

1. Epstein RM. Mindful practice. JAMA. 1999;282:833–839.

2. Lipkin M. Patient education and counseling in the context of modern

patient–physician–family communication. Patient Educ Counsel.

1996;27:5–11.

3. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician–

patient interactions on the outcomes of chronic disease. Med Care.

1989;27:S110–S127.

4. Bird J, Cohen-Cole SA. The three function model of the medical

interview. An educational device. Adv Psychosom Med. 1990;20:

65–88.

5. Lazare A, Putnam S, Lipkin M. Three functions of the medical inter-

view. In: Lazare A, Putnam S, Lipkin M, eds. The Medical Interview.

New York, NY: Springer-Verlag; 1995:3–19.

6. Roter DL, Larson S. The relationship between residents’ and attending

physicians’ communication during primary care visits: an illustrative

use of the Roter Interaction Analysis System. Health Commun. 2001;

13:33–48.

7. Roter DL. The enduring and evolving nature of the patient-physician

relationship. Patient Educ Counsel. 2000;39:5–15.

8. Roter DL. The medical visit context of treatment decision-making and

therapeutic relationship. Health Expectat. 2000;3:17–25.

9. Laidlaw TS, Kaufman DM, Sargeant J, et al. What makes a physician

an exemplary communicator with patients? Patient Educ Counsel.

2007;68:153–160.

S54 PRACTICE-BASED LEARNING AND IMPROVEMENT ACADEMIC PEDIATRICS

Competency 10. Take primary responsibility for lifelong learning to improve knowledge, skills,and practice performance through familiarity with general and experience-specific goals andobjectives and attendance at conferences

Ann Burke, MD

BACKGROUND: Responsibility for one’s own lifelonglearning (practice-based learning and improvement) is aprocess that involves a complex framework of self-direc-tion, self-efficacy, and insight.1–3 The concepts of lifelonglearning and self-directed learning continue to be elusive,with learners and educators finding it difficult to defineand to agree on their role in professional formation andcontinued learning.1

A framework based on the work of Malcolm Knowles1,2

defines self-directed learning as a process in which individ-uals take the initiative, with or without the help of others, indiagnosing their learning needs, formulating goals, identi-fying resources for learning, choosing and implementingappropriate learning strategies, and evaluating learningoutcomes. In 1977, Guglielmino3 developed an instrumentto measure self-directed learning. She defines a self-directed learner, or one who takes responsibility for life-long learning, as

one who exhibits initiative, independence, and persis-tence in learning; one who accepts responsibility forhis or her own learning and views problems as chal-lenges; one who is capable of self-discipline and hasa high degree of curiosity; one who has a strong desireto learn or change and is self-confident; one who is ableto use basic study skills, organize his or her time and setan appropriate pace for learning, and to develop a planfor completing work; one who enjoys learning and has atendency to be goal-oriented.

An excellent exploration of the theories, frameworks, andcomplex considerations of self-directed learning, Self-Di-rection for Lifelong Learning by Candy,4 explores theontogeny of self-direction. It is clear from this text that thereis active discussion and debate about what constitutes life-long learning. When discussing the skills and competenciesof a self-directed learner, Candy points out that although theapproaches to developing a profile of a self-directed learnerhave varied enormously among authors, the lists of skills andcompetencies have a remarkable degree of congruence intheir qualities and characteristics. These qualities includethe following: methodical and disciplined, reflective andself-aware, confidentwith a positive self-concept, developedinformation-seeking and retrieval skills, curiosity, openness,and motivation. Many of these qualities are utilized andembedded in the Jefferson Scale of Physician LifelongLearning, one of the few instruments specifically validatedfor physicians.5–8

The value in diagnosing the stage of self-directness liesin helping the learner move from a less advanced to a moreadvanced stage. Grow9 speaks to the levels of self-directed-

ness beginning with dependent, moving through interestedand involved, and finally culminating in self-directed. Heprovides strategies for teaching learners at each of theselevels as well as tips for helping learners progress alongthis continuum.

DEVELOPMENTAL MILESTONES:

�Depends on external direction to learn. Learns what is required only.Possesses limited learning strategies and/or motivation to developthe concepts more deeply. The learning process is new to thelearner, and he articulates little insight into how he learns or whatstrategies he may use to learn.

� Takes some initiative, but also depends on the help of others toengage in self-assessment and identification of learning needs.Develops some fundamental learning strategies based on hisunderstanding of methods that work for him, and actively seeksways to use those strategies and methods.

�Develops an internallymotivated process of inquiry and reflection thatdrives learning with limited external guidance. Demonstrates theself-confidence and insight into abilities to identify learning needs,develop learning objectives, and identify appropriate resources.

� Drives learning using internal prompts, with self-confidence inabilities to pursue a learning goal and learning plan. Insightful, with ahigh degree of curiosity, as demonstrated by asking complex,thoughtful, and probing questions.

� Demonstrates self-efficacy, insight, and reflection in developinglearning plans and evaluating one’s own learning process. Self-confident in ability to learn and continually reviews the process andprogress of learning.

REFERENCES

1. Murad MH, Varkey P. Self-directed learning in health professions ed-

ucation. Ann Acad Med Singapore. 2008;37:580–590.

2. Knowles M. Self Directed Learning: A Guide for Learners and Teach-

ers. New York, NY: Associated Press; 1975.

3. Guglielmino LM. Development of the Self Directed Learning Readi-

ness Scale [dissertation]. Athens, Ga: University of Georgia; 1977.

4. Candy PC. Self-Direction for Lifelong Learning: A Comprehensive

Guide to Theory and Practice. San Francisco, Calif: Jossey-Bass;

1991.

5. Hojat M, Nasca TJ, Erdmann JB, et al. An operational measure of

physician lifelong learning: its development, components and prelim-

inary psychometric data. Med Teach. 2003;25:433–437.

6. Hojat M, Veloski J, Nasca TJ, et al. Assessing physicians’ orientation

toward lifelong learning. J Gen Intern Med. 2006;21:931–936.

7. Hojat M, Veloski J, Gonnella J. Measurement and correlates of physi-

cian lifelong learning. Acad Med. 2009;84:1066–1074.

8. Hojat M. Physician lifelong learning: conceptualization, measurement,

and correlates in full-time clinicians and academic clinicians. In:

Caltone MP, ed. Handbook for Lifelong Learning Developments.

Hauppauge, NY: Nova Science Publishers Inc; 2009:37–78.

9. Grow GO. Teaching learners to be self-directed. Adult Educ Q.:

125–149. Expanded version available at: http://www.longleaf.net/

ggrow, 1991;41. Accessed September 13, 2013.