Robert D. Fox

Learning and the adoption of innovations among Canadian radiologists

&NA; Although learning and change have been connected in theoretical models of innovation diffusion and change theory, evidence has been limited to qualitative data. Moreover, guidance to practitioners as to how these concepts relate to practice has been limited. In order to evaluate its applications to understanding how learning is related to innovations in radiological practices, a survey based on theories of learning and change was distributed to Canadian radiologists. The study evaluated the relationships described in models presented as explanations of how and why changes are made in medical practices. It focused on the nature of the relationship among types of innovations, images of change as described by learners, and use of learning resources in self‐directed curricula. Of the 1005 members of the Canadian Association of Radiology who received the survey, 352 responses were described. Responses indicated that a variety of resources for learning were used in order to learn about innovations into practice. Type of change was significantly associated with specific types of resources for learning and attributes of the image of change. Continuing education for health professionals should be based on a variety of strategies to facilitate learning rather than a single approach. Continuing medical education (CME) providers should support the self‐directed learning needs of physicians as well as provide courses, workshops, and other traditional forms of CME.

A Conceptual Model of CME to Address Disparities in Depression Care

&NA; The gap between best practices and actual practice in depression care—the difference between “what should be” and “what is”—is wider for ethnic and racial minorities than for the general population. Education alone is not reducing the gap or improving outcomes. Interventions such as the chronic care model have demonstrated improvements in physician performance and patient health status, both in the general population and among ethnic and racial minorities. Recent reviews of continuing medical education (CME) have shown that it is effective when the planned activities include (1) needs assessment and a focus on higher‐level outcomes, (2) multiple ongoing activities that are sequenced for learning, (3) planning that considers the context in which the learned principles will be applied, (4) interactivity, and (5) active learning. The authors describe an approach to planning CME reflecting these five factors and suggest that CME planned in this way be combined with the chronic care model to enhance outcomes further.

Revisiting “Discrepancy analysis in continuing medical education: A conceptual model”

[Editor’s Note: In this preface, Dr. Fox reflects on what he sought to accomplish with the article he published in 1983 (reproduced below). He also comments on how well the concepts addressed in that article have held up over nearly 30 years of research and practice in continuing education for health professionals.] If those responsible for offering continuing professional education cannot explain their successes or failures, one wonders if, in the next program, success can be repeated and failures avoided. Assessment is linked through theory to improvement. The purpose of this article was to introduce the notion of a discrepancy between what is and what ought to be—a gap analysis—as a means to assess needs and outcomes. Needs and outcomes were related to gaps in competencies, clinical performance, and patient health. The paper proposes that gaps in patient health before and after programs can be explained as either due to clinical performance or the effects of other factors (systems). It proposes that gaps in clinical performance can be attributed to gaps in competence or to other factors, such as barriers to change. This inductive and deductive reasoning and the formal explanations associated with gaps uncovered in assessments were

Implications of the model of change and learning for undergraduate medical education

&NA; This essay responds to the need for closer intellectual ties between continuing medical education (CME) and the undergraduate experience. Medical educators in each of these two phases of lifelong learning are often unfamiliar with the implications of research in each phase for the other. In order to redress this, this essay describes one of the major explanations for change and learning in clinical practice and draws implications of this model for the education of undergraduate medical students. The model includes the role of forces for change, image of change, assessment of needs for learning, and the use of learning resources in a self‐directed curriculum. Specific implications for each of the phases of the change process are offered. General implications of the model and a set of new assumptions for the development of formal curriculum in undergraduate medicine are also described.

Proficiency assessment : a tool for developing geriatric education programs and for predicting program participation

Geriatric education centers are responsible for providing geriatric training opportunities that meet the needs of an interdisciplinary range of health care professionals. Proficiency assessment measures the discrepancy between what professionals perceive they do know and what they perceive they should know, and provides a tool for planning and predicting attendance at educational programs among such professionals. Implementation of a proficiency‐assessment tool at the Ohio Valley Appalachia Regional (OVAR) Geriatric Education Center successfully identified 10 out of 27 items that predicted attendance at a selected geriatrics program. Techniques are suggested for instrument design and distribution, data collection, coding, and data analysis and interpretation.

Diary use for physicians to record self-directed continuing medical education

&NA; A pocket‐size diary was offered to 4005 volunteers, physicians, and surgeons practicing across Canada in 10 specialties. Volunteers were requested to keep records of their self‐directed continuing medical education (SD CME) activities for a period of 10 months in 1993. At the end of this period, they were surveyed to determine use of the diary, their opinion about keeping records of SD CME activities, and their acceptance of the MOCOMP* programs philosophy. A second survey was undertaken of volunteers who had not used the diary. A total of 2188 volunteers responded to the survey. Of those, 56.6% reported using the diary. Respondents concurred with four statements in the survey, which correlated with their reported use of the diary. A significant positive association was found with statements concerning their understanding of what to record, identifying which keywords to enter into the diary, and whether recording SD CME activities helped them to think about the care of patients. No correlation was found between recording activities and the ability of physicians to identify a potential impact that the SD CME activity may have on their practice. The number one reason given by those who did not complete their diaries was an abhorrence to filling in forms. Overall, the degree of compliance in using the diary was encouraging. Additionally, over two thirds of the volunteers who used the diary reported that they would personally recommend the MOCOMP program to their colleagues. The next steps for the program include developing a software tool to enhance the educational value of a personal diary for SD CME activities.

IMPROVING GERIATRIC HEALTH CARE: THE ROLE OF EDUCATION

A look to the past shows how education shaped the contemporary system of health care. The consequences of the structure of this system on health care of the elderly are discussed. We also describe an image of health care in the future based on the needs of the elderly. There are two courses of action that can be followed as the United States moves toward the first half of the 21st century. One course accepts the structure and direction of the contemporary system. The other suggests a reorganization of the health care system based on current and future needs of the population and the nature of resources available. Both of these courses of action are discussed and examples of existing programs cited. We believe medical educators must make the necessary changes toward one or both of these courses of action now to ensure improved geriatric health care in the future.

Changing and learning in geriatrics/gerontology: A retrospective

&NA; The purpose of this study of health care professionals was to find answers to the following research questions: (1) What changes related to geriatrics/gerontology occurred in the last year? (2) If changes occurred, what factors caused or led to those changes? (3) Did learning play a part in the changes? Twenty randomly chosen participants in the First Summer Geriatric Institute were questioned using a semi‐structured interview format. Data analysis was performed using the constant comparative methods. Changes were categorized by types (i.e., accommodations, incremental changes, and structural changes). Each change was then analyzed according to the models framework (i.e., forces for change, clarity of image of the future change, self‐assessment of learning needs, and learning activities). One half of the changes were found to be incremental changes, consisting of adjustments in some element of life or practice. The other half were structural changes involving complex additions, subtractions, or reorganization of major elements. Participant responses indicated that multiple forces were involved in each change; change was a long process involving a series of interrelated experiences. Analysis of the forces initiating change revealed that professional forces were the strongest initial forces for change, followed closely by professional/social forces. Although learning accompanied every change, the change process varied according to the type of change (e.g., workshops or classes were chosen by those making incremental changes, while colleagues and experience were chosen by those making structural changes).

Most frequently cited publications in continuing nursing education: 1980 to 1990

&NA; This article reviews information gleaned from a citation analysis of the literature from the field of continuing nursing education (CNE). The analysis was limited to articles published in refereed American journals from 1980 to 1990. The fact that these articles were frequently cited within CNE literature indicates their importance to the field of nursing. The compilation of these data provides those in nursing the opportunity to become more effective in self‐examining their own field and the direction of its growth. In addition this information provides researchers in other fields a sense of the tradition and direction taken by the field of nursing and could open the possibility for joint avenues of research. The target number of publications was 20, but because many publications were cited equally, 13 books and 10 articles were selected.