Closing the clinical practice gap

At the end of the last century, a York University review noted that: 'The naîve assumption that when research information is made available it is somehow accessed by practitioners, appraised and then applied in practice is now largely discredited.'

In the same year, a somewhat scandalous research article published in The Journal of the American Medical Association (JAMA) revealed that medical guidelines themselves were …ahem … not following the guidelines. A trifle embarrassing perhaps. What chance did anyone else have?

Should the authors of those articles have had access to, say, a tampered-with DeLorean that enabled them to accelerate to the present day, would they have been impressed with the progress they have made?

While the gap between evidence and practice is old-but-stubbornly-persistent news, it is pleasing to note how far we have come. Much of this evolution comes from our changing insight into the necessary conditions under which medical education can drive real change in clinical practice.

We now understand that educational approaches that fail to follow the principles of instructional design are unlikely to have optimal practice-enhancing benefit. For those who know all about instructional design: stop here, thanks for reading. For those who don't, here are some tips.

Step 1: Be sure to target the actual problem
Don't design education based on the faculty's pet teaching topics or even someone's informed perception of the clinical practice deficit. You run the risk of teaching what is already known and missing the real opportunity.

Any educational intervention that intends to close a clinical practice gap must be prefaced by a formal needs assessment of some kind. This is a research process among potential learners, or a representative population, through which the nature and causes of the gap are fully elucidated. It is the essential precursor to highly targeted and effective education.

Step 2: Be driven by appropriate objectives
If step one was done well, then step two – creating clear learning objectives that will drive your programme design – should be relatively straightforward. But beware: a learning objective that intends for doctors to know something will help you to create education that transmits knowledge.

To change practice, however, your objectives must articulate what it is that should be done differently after the educational intervention has completed.

Step 3: Design the activity to deliver change
Clearly, awareness is foundational. However, as the authors of the York review acknowledged back in the 90s: '… while knowledge of a practice guideline or a research-based recommendation may be important, it is rarely, by itself, sufficient to change practice.'

Indeed, this simple statement summarises what has become something of a paradigm shift in medical education over recent decades. We now know only too well that passive learning – the simple one-way transmission of knowledge that had long-dominated educational initiatives – is rarely (if ever) an effective means of bringing about practice change. 

We also understand that live interactions change more than print ever could. Blended learning – that combines multiple channels of education – has greater impact than single media. Repetition is the time-honoured friend of effectiveness in influencing behaviour: practice-changing education is no exception.

Use a richly diverse range of approaches to target the changes you need to effect and then go ahead and measure your success by assessing actual changes in physician competence, performance or even patient outcomes. You may be pleasantly surprised!

The Author
Dr Alisa Pearlstone, director of medical education at PCM Scientific and founding director of PCM Healthcare.
PCM Scientific is a member of the Good CME Practice Group
alisa@pcmscientific.com