Critical reflection on effective life-long learning – interventional cardiologists in pandemic times

Postgraduate learning refers to a specific form of education aiming to help healthcare professionals (HCPs) consolidate competence and learn about information in their field.

Because of the current COVID-19 environment with an exponential development of ‘digital format of postgraduate learning events’, often on the same topics, it seems essential to remember the foundation of effective post graduate learning in the field of medicine, and how we can achieve this goal. In this article, Jean Marco urges educators to put learners at the centre of the educational process!

What are we talking about?

Placing the learner at the very centre of the learning process

The motivations of adults taking the time for their own postgraduate learning, regardless of the format (reading, attending face-face meeting, watching and listening to digital events), are a self-directed and clear reason for learning, most often based on problem-solving needs, that will help them to consolidate their professional competency in their daily tasks. (2)

Accordingly, the fundamental goal of postgraduate medical learning is to consolidate the professional proficiency of HCPs. This helps them to select and apply the most appropriate and economically sustainable management or technical strategy for each individual patient presenting with a specific clinical situation. This needs to be carried out in the light of their self-reflection on knowledge, experience, and the local constraints they face. The consolidation of professional proficiency is the main goal and reflecting on knowledge and experience is the means to reach this goal.

What is at the heart of the problem?

HCPs are overloaded with a continuous flow of information. Because of the easy access to information via digital tools, and in the current COVID-19 environment the multiplications of digital postgraduate events - often on the same topics - are the sources of disorienting dilemma or of cognitive conflicts.

As HCPs, at each step of our career, we develop personal learning needs and expectations. These are based on our own reflection on the information, our level of experience and knowledge and the changes we want to make in our professional practice. We also have the means to select the most appropriate learning format that will help to consolidate our professional proficiency. This progressively pushes us towards the paradigm of “self-directed learning” (3-4).

It follows from this that the learners themselves need to be involved in selecting what should be included in their learning programmes and not just faculty, course directors or speakers who select what the attendees need to learn and hear, the learning material and how the learning content should be delivered and assessed (5). This new approach requires a new learning process – one that is built around the active involvement of participants. It needs to incorporate their experience and provide the opportunity to self-reflect on the information disseminated to achieve effective learning outcomes. This sounds like it might be a difficult thing to do, but it is not.

What does an effective postgraduate learning outcome actually mean?

A postgraduate syllabus, session or lecture is considered effective by the participants when the objectives are participant-oriented, clear and in line with their needs and expectations, both the framework and working flow are logically linked with the objectives and are easy to follow, the content is oriented towards problem solving rather than information, and delivery is conducted by charismatic educators who facilitate participants’ autonomous thinking, using appropriate media to help developw clear messages.

Effective postgraduate learning really takes place when participants are placed at the centre of the learning process and take an active part in it.

What is the new role of educators?

First, and most importantly, it is to encourage everyone involved to explore and understand the learning expectations (and needs) of a target audience on a particular topic.(6)

Learning has to be oriented towards problem solving and it needs to stimulate the learners (participants) to reflect critically on their knowledge and experience (2).

A helpful starting point for educators is to ask themselves a few simple questions. As an example, for a learning syllabus or session dealing with skill or behavioural problems (7):

• What problems or dilemmas am I facing in this field?
• What do I need to change to resolve these problems and improve my performance?
• Do my colleagues or peers, working in other institutions or in different regions or countries or with different levels of experience in the field (our target audience) face the same patients and problems?
• What specific things will help them improve their performance in the field?
• Do they have all the same means available as I do to solve the same issues?
• What potential barriers may get in the way of my colleagues improving their outcomes in the field?
• What do I need to do, to find out if my colleagues are facing the same problems or dilemmas in the field? Starting with self-examination of issues and critical assessment of assumptions is helpful for identifying learning expectations.

When preparing a learning syllabus or session aiming to reflect on knowledge, it requires a more self-reflective process. We can do this by asking ourselves:

• What was the state of our ignorance in this field (what didn’t we know) 1 or 2 years ago?
• What is the state of our ignorance (what we don’t know) today?
• What are the 1 or 2 pieces of peer-reviewed published information that created change during this period?

New information is quickly and widely disseminated and all HCPs have easy access to information. Asking the following questions can be helpful:

• Did I scientifically and critically analyse the whole content and the limits of the information?
• Do I consider the information to be essential to provide patients with a better clinical outcome?
• What arguments could support my judgement?
• Is it strong evidence or is it just an interesting hypothesis?
• Do I consider this information as interesting and to be shared with my audience?
• What would be the purpose of doing this? To stimulate participants’ critical reflection or to stimulate raising questions? We have to be clear about the purpose!

Moving towards a participant-oriented paradigm

To move towards a participant-oriented paradigm is essential to assess whether the problem or gap we identified is currently relevant to the needs or expectations of the target audience. This is where digital tools and web-based enquiries can really help. Once educators really understand the learning gaps and expectations of the target audience, they can set clear proficiency-oriented objectives for the participants that foster their autonomous thinking and critical reflection. (8)

To set clear proficiency-oriented objectives for participants that foster their autonomous thinking and critical reflection (6-7-8). Autonomous thinking simply means thinking for ourselves and making our own judgement. Critical reflection is the process we use to evaluate our current practice, think about what is desirable, consider what is possible, and develop new understandings that inform our actions.

Proficiency-oriented objectives are those that focus on improving performance for successful achievement of defined tasks. Educators need to specify what we want  participants to acquire, at the end of the syllabus or session (outcomes we want to be achieved), why and how this will be done.

WHAT: these are the things that participants will acquire or be able to do to improve their proficiency. What is essential and what is only interesting, and for what purpose.
WHY: to help HCPs to propose what is most appropriate for the best patient outcomes.
HOW: is the process we use to help participants’ critical reflection (i.e., a step-by-step decision-making approach…or evidence-directed decision making or other…) practical and applicable the next day or in the near future, or for another topic?

The learning objectives will help educators to identify the real outcomes needed to improve performance and patient outcomes.

Once educators know what is needed, the next step is to set about designing the framework that delivers the learning objectives by stimulating the autonomous thinking of the participants on their knowledge, information and experience.

How to set about designing a framework logically linked to these objectives?

To achieve these goals, educators always have to start by clarifying the key messages and then think about the key sections needed to deliver them. For example, in order to help participants to understand or to do… (Two to three objectives), the following two or three sections are needed. Then, write down the key messages we want the participants to retain at the end of each key section like this:

At the end of section one, the participants will be able to retain…in order to…

Educators need to be realistic with the allocated time and the capability of participants to participate, maintain their attention and ability to remember, by selecting only the essential or interesting information and the experiences they want to share.

Adopting the Plus, Minus, Interesting (PMI) learning concept (8) is useful:

Plus: these are the essential messages that you need to deliver. Remember, your audience has easy access to information overload …they want you to guide them on the essentials!
Minus: is the devil who orders speakers to be exhaustive and not to forget something. The fear of not being credible. Ignore what is not essential: it will cause participants to become discontent.
Interesting: be clear about why you are including something, e.g., is it to stimulate questions or comments from the participants? Be sparing, use as few examples as possible.

The other essential point when preparing the framework and timeline is to leave enough time for the unpredictable, i.e., an unpredictable question or comment. Flexibility has to be a part of the framework. The participants will appreciate it!

References

1. Mezirow, J. Learning as Transformation: Critical Perspectives on a Theory in Progress. San Francisco, CA, USA: Jossey-Bass Ed.; 2000.
2. Knowles MS, Malcolm M, Holton EF, Swanson RA. The adult learner: The definitive classic in adult education and human resource development (6th ed.). Burlington, MA,USA: Elsevier; 2005.
3. Kitchenham A. The Evolution of John Mezirow’s Transformative Learning Theory. Journal of Transformative Education. 2008;6:104-10.
4. Daily JA, Landis BJ. The journey to becoming an adult learner. From dependent to self-directed learning. J Am Coll Cardiol. 2014;64:2066-8.
5. Duty FD, Holmboe ES. Self-assessment in life-long learning and improving performance in practice: physician know thyself. JAMA. 2006;296:1137-9.
6. Asch DA, Weinstein DF. Innovation in medical education. N Engl J Med. 2014;371:794-5.
7. Nicolaides A, Dzubinski L. Collaborative development action inquiry: an opportunity for transformative learning to occur? Journal of Transformative Education. 2016:14;120-138.
8. Kizlik B. How to write learning objectives that meet demanding behavioral criteria. http://adprima.com/objectives.htm
9. Delany C, Golding C. Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC Med Educ. 2014;14:20.

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Date of publication: 17 December 2020