SGIM Forum

Medical Education: Part I

Faculty Self-Directed Learning: COVID-19 as a Catalyst

Dr. Raffel (katie.raffel@cuanschutz.edu) is an assistant clinical professor in the department of medicine at Denver Health, University of Colorado. Dr. Fuller (Jessica.fuller@ucsf.edu) is an assistant clinical professor in the departments of medicine and pediatrics at the University of California, San Francisco. Dr. Kulkarni (shradhakulk@gmail.com) is an assistant professor in the department of medicine at the University of California, San Francisco. Dr. Fenton (Cynthia.Fenton@ucsf.edu) is a professor in the department of medicine at University of California, San Francisco. Dr. Narayana (sirisha.narayana@ucsf.edu) is associate professor of medicine at the University of California, San Francisco.

The COVID-19 pandemic is a humble reminder of the continuous nature of personal clinical growth. While hospitalist faculty see value in self-directed learning (SDL)—setting predetermined goals, eliciting feedback, and promoting repetition—most cite multiple barriers to such practice, including immediate demands of patient care that constrain time and cognitive bandwidth, exposure to a wide range of low prevalence diseases, and limited access to tools and programs.1

Prior to the COVID-19 pandemic, our hospitalist group was developing a program to foster self-directed learning through patient follow-up and shared group-learning. In a small group setting, hospitalists would review evidence-based guidelines, reflect on the clinical courses of prior patients, and evaluate their practice for concordance or discrepancies. The SDL cohort had a single session prior to the abrupt alteration in practice due to COVID-19. At our institution, this upheaval actually facilitated a rapid and iterative learning environment. On a much larger scale than pre-pandemic, hospitalists adopted behaviors associated with master clinicians: daily reading of primary literature, rehearsing clinical reasoning scripts, tracking patient outcomes, rigorously analyzing cases, and learning from peers in real-time.2 Intrinsic motivation became more pronounced, driven by three key domains of autonomy, competence, and relatedness.3

We describe insights into these domains as they relate to COVID-19, and how this experience may be used to optimally foster intrinsic motivation for SDL in future faculty development efforts:

  1. Autonomy: The pandemic created a “need to know” (or “need to learn”) for everyday clinical decisions that could not be answered by calling on experts or looking to a guideline. This resulted in heightened sense of self-reliance or autonomy for hospitalists. The associated marked increase in SDL behaviors raised the question of how a hospitalist program could leverage autonomy when focusing on diseases where guidelines and specialists are widely available. While our program initially planned to focus on the general application of guidelines, after further appreciating the importance of autonomy, we pivoted to include discussion of more nuanced applications, such as a focus on guideline exclusion criteria. Using discussion and debrief of participants’ cases, we aim to both refine clinical judgment and highlight the role of hospitalist autonomy by focusing on warranted and unwarranted exceptions to guidelines linked to actual patient outcomes.
  2. Competence: In addition to the autonomy afforded to hospitalists by being de facto experts for patients with COVID-19, the opportunity for repetition (“practice”) due to the unfortunate reality of surges inspired confidence that competence could be achieved. Knowledge gained through self-directed learning was utilized, extended, and reinforced daily while on the COVID-19 service. The positive feedback loop drove what appeared to be an insatiable need to gain more knowledge and more competence. This observation reinforced the programmatic importance of focusing on disease processes that are highly relevant (prevalence-based), urgent (due to gaps in care or adverse events), and allow for hospitalist ownership. Such topics may include addiction medicine, community acquired pneumonia, venous throm boembolism, and prognostication and advance care planning in patients with malignancy.
  3. Relatedness: Motivation for SDL is spurred by a sense of relatedness.4 In our initial program design, we anticipated that clinicians would experience a sense of relatedness by following up on patients with whom they felt a connection and/or those that added social meaning to provider’s work.5 During the COVID-19 era, however, we discovered that the social aspects of learning could extend beyond the traditional institutional walls. Meaningful collaboration and connections formed with colleagues at other institutions, many of whom experienced overwhelming surges of COVID-19 patients. There was a profound empathy for our colleagues and a sense of duty of sharing learning with one another. COVID-19 learning has demonstrated that relatedness, as a driver of SDL among clinicians, can extend beyond the accountability and interdependence with our patients and local colleagues to include connections with hospitalists at other institutions and with society more broadly.

COVID-19 acutely transformed our learning climate, and while we may not want to model all aspects of this education disruption, the pandemic has offered us the opportunity to improve our approach to faculty development by more deliberately considering and incorporating principles of autonomy, competence, and relatedness. By developing programs that focus on common and urgent diagnoses and incorporate nuanced guideline application as well as expanded peer engagement, intrinsic motivation is cultivated and emergence of self-directed learning more likely.

References

  1. Jeong D, Presseau J, ElChamaa R, et al. Barriers and facilitators to self-directed learning in continuing professional development for physicians in Canada: A scoping review. Acad Med. 2018 Aug;93(8):1245-54.

  2. Murthy VK, O’Brien B, Dhaliwal G. An inquiry into the early careers of master clinicians. J Grad Med Educ. 2018 Oct; 10(5):500-506.

  3. Deci EL, Ryan RM. Self-determination theory. In Van Lange PAM, Kruglanski AW, Higgins ET. (Eds.). Handbook of Theories of Social Psychology. Newbury Park (CA): Sage Publications Ltd.; 2012:416–36.

  4. Bowen JL, Ilgen JS, Irby DM, et al. You have to know the end of the story: Motivations to follow up after transitions of clinical responsibility. Acad Med. 2017 Nov; 92:S48-S54.

  5. Cook DA, Artino AR. Motivation to learn: An overview of contemporary theories. Med Educ. 2016 Oct; 50(10):997-1014.


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