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Physicians' Learning Strategies*
H. B. Slotnick
Chest 2000;118;18S-23S
DOI 10.1378/chest.118.2_suppl.18S
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Physicians’ Learning Strategies*
H. B. Slotnick, PhD, PhD
This article examines the two categories of learning strategies that physicians use in clinical
practice. The strategies are similar in their overall architectures and differ (1) according to nature
of the clinical problem that precipitated the need to learn, and (2) the ways in which learning
resources are used.
(CHEST 2000; 118:18S–23S)
Key words: adult learning; learning theory; physician learning
Physicians’ Learning Episodes
describing physicians’ learning sugT hegests,literature
first, that doctors learn in response to
either specific problems (eg, problems posed by
particular patients) or general problems (eg, updates
on bodies of skill and knowledge),1–3 and second,
that each problem type is associated with a particular
form of physician learning. These forms are (1)
semi-structured learning (eg, available reading and
consultation sources) that are used to resolve specific
problems, and (2) formal learning (eg, planned learning projects, courses at specialty society meetings)
that are used to address general problems.4 Third
and finally, learning the solutions to specific problems results in incremental additions to a doctor’s
knowledge and skill, while learning associated with
general problems produces changes to larger “elements” of the doctor’s life and practice.5
There is also a set of patterns called learning
episodes that describes the stages doctors move
through in going from the specific and general
problems that precipitate learning to learning outcomes. These stages have been described by Fox and
his colleagues,6,7 as follows: (1) doctors deciding
whether to take on a learning task; (2) learning the
skill and knowledge anticipated to resolve the problem; and (3) gaining experience using what was
learned in a variety of settings.
This formulation has recently been expanded to
make it more congruent with doctors’ clinical learning activities.8 The first change was the addition of a
*From the Department of Neuroscience, School of Medicine &
Health Sciences, University of North Dakota, Grand Forks, ND.
Correspondence to: H. B. Slotnick, PhD, PhD Department of
Neuroscience, School of Medicine & Health Sciences, 501 N
Columbia Rd, Grand Forks, ND 58203; e-mail: slotnick@
medicine.nodak.edu
fourth stage (scanning), in which doctors examine
their environments both for problems that might
precipitate learning and for ideas, proposals, etc.,
that may be useful to them in the future, although
they have no immediate need for them.
The second change concerns the manner in which
the remaining three stages are manifest as a function
of the type of the precipitating problem. In particular, specific problems progress rapidly and make use
of immediately available learning resources, while
learning associated with general problems is more
deliberative and uses immediately available resources as well as those requiring more effort before
they could be accessed (eg, courses at specialty
society meetings). The issue of which resources are
used as a function of problem type and stage will be
considered later in this article.
The third change is the addition of clear, although
unstated, criteria used to describe whether learning
should continue on to the next stage or should
terminate (which means the physician returns to the
scanning stage). The four stages are presented as a
function of problem type in Table 1.
Differences among the stages can be understood
in terms of the goal of each stage; the discrepancy
resolved during the stage (ie, what is needed to
address the goal); the way learning resources are
used; the reflection (ie, the thinking) the doctor does
during the stage; and the criteria to be satisfied
before the stage can be considered complete. The
criteria are of particular interest because they bear
on whether a doctor’s aborting a given learning
episode before completion of the last stage is justified or unjustified. The stages are compared and
contrasted in terms of these attributes in Table 2.
One final point needs to be made about the stages,
and it concerns the criteria for the completion of
each stage. Although medicine is certainly a profes-
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Table 1—The Four-Stage Theory of Physician’s Self-Directed Learning Episodes*
Learning Stage/Problem Type
Specific (eg, Addressing a Patient Need)
General (eg, Updating Bodies of Skill and Knowledge)
Stage 0/Scanning for problems and
other interesting things.
The doctor is alert for potential
resources.
The doctor is also alert for problems that he might
need to solve and, when potential problems are
encountered, he moves on to the next stage .
Stage 1/Evaluating the problem:
deciding whether the potential
problem encountered is worth
pursuing.
The doctor senses a need for immediate
action and decides on the spot
whether to take on the problem;
alternatively, the doctor reads a bit,
talks with others, and decides quickly.
The doctor feels uneasy (“Maybe I should review that
stuff . . . ”) and asks: Is this really a problem? Is
there likely a solution to the problem? Are resources
available so I can do the required learning? Am I
prepared to make the changes in my practice
required by the learning I do?
Stage 2/Learning skills and knowledge:
Learning what is needed to address
the problem.
Learning involves reading (typically
journals, less often texts) and talking
with others who offer suggestions.
Learning involves comprehensive reading and taking
available and appropriate courses.
Stage 3/Gaining experience using what
has been learned.
Learning means trying the problem
solutions on the problem in question
and seeing what happens.
Learning means trying the new skills and knowledge
in a range of settings and gaining experience as a
result. It also means reading again, although now
the purpose is not to learn the new thing but to see
what kinds of experiences others have had with it.
*Reprinted with permission from Slotnick.8
sion, and so has its own proprietary body of technical
(indeed, scientific) skills and knowledge,9 science
does not figure prominently in doctors’ deciding they
know enough to end one stage and begin the next
one. This is both understandable (physicians lack the
time to remain current on all the scientific developments in their areas of practice expertise) and troubling (absent attention to scientific developments;
how can a doctor understand the impacts her actions
have on her patients?). Resolution to this dilemma
appears in the criteria doctors use to end each stage;
in each case, doctors adopt approaches that are
practical vs theoretical. Thus, a doctor may abort a
learning episode at stage 1 (evaluating the problem)
because he does not think a solution exists (see
Gorman et al10), or proceed from stage 2 (learning
the skills and knowledge) to stage 3 (gaining experience) without exhausting the research literature
because a consultant and an article read both provided the same solution to the precipitating problem.8 In both cases, time is saved that can then be
used for other purposes, and scientific rigor is assumed rather than confirmed. See Slotnick8 for a
more complete discussion of the criteria used to end
learning stages.
Summarizing to this point, the existing literature
on how doctors learn makes three claims:
1. Physicians’ self-directed learning activities vary
with both the nature of the problem precipitating the
learning episode and the stage the doctor is at in
resolving the problem.
2. Stages in self-directed learning episodes are distinguished from one another in terms of their goals,
discrepancies, learning resources, reflection, and criteria for completion.
3. Self-directed learning episodes can terminate for
reasons that may or may not be justified. The doctor
then returns to the scanning stage.
Left unresolved is the question of where doctors turn
for skills and knowledge they need to complete each
stage, the question considered in the next part of this
article.
Learning Resource Use
The same study that expanded the description of
physicians’ learning episodes also indicated that the
resources doctors use to address specific problems
(eg, those presented by particular patients) are those
that are immediately available to them8 (also see
McClaran et al3 and Slotnick et al,1,2). These include
the journals that doctors subscribe to; reference
materials available in the office, such as the Physicians’ Desk Reference; and physicians doctors talk
with regularly (eg, partners, regularly used consultants). Indeed, these sources are those identified in
meta-analyses of doctors’ resources as having certain
attributes11,12: accessibility (ie, resources are easily
locatable, information needed can be quickly found
within the resource, and the information is readily
understood); applicability (ie, the information and
skill located is clearly related to the clinical problem
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Table 2—Attributes of Learning-Episode Stages*
Stages
Attribute
Goal
Discrepancy
Learning
resources
Reflection
0
1
2
3
Identify potential
problems to
consider during next
stage, and note
potentially useful
issues.
Doctor needs
problems whose
solutions will satisfy
Maslowian needs.3
All aspects of practice
and daily life.
Decide whether the doctor should
learn what is necessary to
resolve the precipitating
problem.
Learn the knowledge and skill
necessary to begin resolving
the precipitating problem.
Apply and become comfortable
with what has been learned
in resolving the precipitating
problem.
The doctor lacks sufficient
information to decide whether
to pursue the problem’s
solution.
Specific problem: the clinical
situation, reading, discussion
with other doctors.
General problem: reading,
conversations, information at
meetings.
Specific problem: focus on
patient, available reading and
consultation; context varies
from clinical and immediate to
consultative and deliberate;
purpose is to address the
questions under discrepancy.
General problem: focus on
information on skills and
knowledge to be learned;
context is consultative,
deliberative, and occurs
anywhere; purpose is to answer
discrepancy questions above.
The doctor lacks the skills and
knowledge necessary to
begin resolving the
precipitating problem.
For specific problems,
primary sources are reading
and consultation. For
general problems, they are
reading, consultation, and
courses.
Specific problem: focus is
knowledge and skill needed
to resolve the problem;
context is typically clinical
and immediate; purpose is
to learn procedures for
addressing the problem.
General problem: focus is
reading, and context is
deliberative and/or handson; purpose is to gain
sufficient knowledge and
skill to begin using the new
learnings in resolving the
precipitating problem.
Situation-specific indications:
the problem requires
action, resources were
exhausted, others (eg,
instructors) told the
physician it was time, there
was nothing more to study.
Doctor-specific indications: an
acceptable plan existed, the
doctor felt ready, the
doctor was clear on what
was to happen next, or the
doctor felt there was no
value in additional learning.
The doctor lacks experience
and/or confidence in what
he is doing.
Focus on probable fit
with doctor’s life
generally, practice
in particular.
Relationship of
problems,
information, and
issues to practice is
a central feature.
Criteria for Problem, issue, or
completion information seems
interesting or
important enough to
be considered
further.
Answers realized to the following
questions: Is there really a
problem? Is there likely a
solution to the problem? Are
resources available for the
physician to do learn what is
required to solve the problem?
Is it practical for the doctor to
do the learning?
Primary sources are those used
already and experience using
the skills and knowledge
learned. Doctors also seek
others’ experiences in similar
situations.
Postmortems of what
happened occurred in both
specific problem and general
problems. The focus was on
the doctor’s experience as
well as prior knowledge and
experiences, the context is
deliberative and may or may
not be at the site of the
action, and the purpose(s) to
evaluate and gain
experience. The experiences
of others (both personal and
published) is reflected upon
as well.
All criteria were situation
specific in the sense that the
doctor gained enough
experience to be confident
with the new learnings. This
was evidenced by the
doctor’s no longer
consciously considering his
or her actions, or the
doctor’s attention shifting to
other issues. The stage could
also end because the
precipitating problem
resolved and the doctor
lacked further interest.
*Reprinted with permission from Slotnick.8
at hand); and familiarity (ie, the doctor has used the
learning resource regularly in the past).
Left unresolved is the question of which resources
doctors use to find the skills and knowledge needed
to address general problems. Answers to this question arise from the preliminary findings of study of
physicians’ learning resource use.13 A random sample of North Dakota physicians were asked to indicate which resources among a list of 43 a physician
would use to find solutions to a general problem (ie,
updating) with problems arrayed along two dimensions: (1) stages of learning episodes (note that
scanning was not included since it is done “intuitively” and so considers all resources a doctor might
encounter); and (2) the nature of the general problem precipitating learning (ie, updating on a commonly seen disease, updating on a commonly used
diagnostic approach, updating on a commonly used
therapeutic approach, and updating on a commonly
used therapeutic technique). Thus, the study was
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able to address questions including the following:
Which resources are commonly used in addressing a
variety of general problems? Is there a difference in
the number of resources used moving from one
episode stage to the next? Is there a difference in the
number of resources used for addressing different
varieties of general problems?
Preliminary findings from the study suggest that
the resources doctors use to address general problems are the same as those used for specific problems (ie, talking with same specialty colleagues, and
reading journals available in the doctors’ offices),
augmented by some that are not immediately available and so are not used in solving specific patientcare problems (ie, attending specialty society meetings, talking with doctors at such meetings, and
journals available at the medical library as opposed to
those in the doctors’ offices). These findings make
sense; the lack of immediacy associated with general
problems means that doctors can use resources that
require planning before they can be accessed.
Preliminary findings also suggest that the number
of resources used varies with the general problem
varieties and stage, although the statistical interaction observed to exist between these two factors
complicates interpretation of findings. Examination
of the interaction suggests the following:
1. Regardless of problem variety, the smallest number of learning resources are at the gain experience
stage. Smaller numbers of resources are likely
needed, since this is a largely experiential activity;
while it is true that physicians value sharing experiences with other doctors, it is also true that a doctor
needs to gain and reflect on experience if he or she
is to internalize it. This is true across all problem
varieties.
2. More learning resources are used at stage 1
(evaluating the problem to decide whether to learn
to solve it) and stage 2 (learning the skills and
knowledge) for a disease update than updating on a
therapy or a diagnosis. The problem varieties vary
across both stages (evaluating the problem, and
learning the skills and knowledge) in terms of the
numbers of resources used. It is likely that more
resources are needed for updating on disease than on
diagnosis or therapy because information on disease
tends to be developed in and to be available from
research centers, while information on diagnosis and
treatment is more likely locally available.
3. While the number of learning resources is generally the same for both diagnosis and therapy, there is
a small but statistically significant difference between therapeutic approach and therapeutic technique, the difference being that fewer resources are
needed to learn the skills and knowledge for the
therapeutic technique than for the therapeutic ap-
proach. The interaction of therapeutic approach vs
therapeutic technique with stages indicates that
learning the skills and knowledge associated with the
technique requires fewer resources than the approach, probably because one learns how to do
something (technique) by doing it, and one learns
about an approach by reading and discussing what
one reads with others, such as colleagues.
In summary, there are differences in the resources
accessed in resolving general problems, and the
differences are very much a function of both the
problem the doctor is learning to solve and the stage
the doctor at while learning the solution. The implications of these findings are the subject of the last
section of this article.
Recommendations
Knowledge of the way a process works offers
opportunities to both understand it and invoke it in
striving toward desirable ends. In the case of medicine, applying this kind of understanding in clinical
and public health settings allows interventions that
prevent illness and treat it when it appears; in the
case of medical education, applying this kind of
understanding allows interventions that facilitate clinicians’ practices by allowing doctors to learn skills
and knowledge when they encounter the problems
that require the skills and knowledge. How these
medical education ends are reached is the subject of
the balance of this article.
It has long been known that adults, generally,14
and physicians, specifically,15 learn in response to
problems they perceive they have. It is now clear that
simple recognition of a problem, while necessary to
ensure learning, is not sufficient in and of itself. First
the doctor must evaluate the problem to decide the
following: (1) if it is really is a problem he or she
should handle; (2) whether the problem likely has a
solution; (3) whether the resources needed to resolve
the problem are available; and (4) once learning has
taken place, whether he or she is prepared to change
his or her practice in order to solve the problem that
precipitated the learning.8 The recommendation for
those who would teach doctors is that they must first
provide information allowing learners to decide
whether to take on the learning project, since proceeding directly to teaching the skills and knowledge
may be entirely premature. An example will show
how this works.
There is currently concern about the use of pulmonary artery catheters.16 –20 If one wishes to change
practitioners’ use of the catheters to resolve these
concerns, one must first convince these same practitioners that learning the required skills and knowlCHEST / 118 / 2 / AUGUST, 2000 SUPPLEMENT
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Table 3—Action Taken in Moving Through a Learning Episode
Action
Nature of Justification
Move to Next Stage
Abort Learning
Actions justified
Move to next stage for justifiable reasons.
Actions not justified
Move to next stage for unjustifiable reasons.
edge is indeed going to help them solve problems
they already recognize they have.19 Recall that the
first criterion doctors use in stage 1 (evaluating the
problem) is, Is this a problem for me? Therefore,
knowledge of the problems potential learners face in
their practices and ways they approach them is
simply a necessity.
Similarly, it appears that doctors likely use the
same resources in evaluating the problem and in
learning the skills and knowledge required to complete the stage of learning they are at. Since the
criteria are different at each stage (see Table 2) while
the resources are often the same, it is clear that the
ways in which doctors use resources at each stage is
different. The recommendation for anyone who
would teach practicing clinicians is that the doctors
in their audiences are looking for different things
from the presentation they are seeing, depending on
where they are in the learning process; pointing out
the applicability of what one is teaching for those at
each point in the learning process helps ensure that the
needs of different audience segments will be met.
Finally, there is the issue of documenting the
outcomes of learning, and this leads to two recommendations. Recognizing that each stage can end in
two ways (move on to the next stage vs terminate
learning and return to scanning), and that the decision can be either justifiable (the basis for the
decision is “valid”) or unjustified, documentation of
learning outcomes needs to consider the four possibilities shown in Table 3. Recall that the criteria
doctors use for ending each stage in a learning
episode are practical vs theoretical. This means that
justification of a doctor’s actions can only be made by
looking at what the doctor did (eg, how the doctor
ended the learning episode), and the doctor’s criteria
for making the decision that resulted in the action
taken. The first recommendation, then, is that anyone who evaluates educational activities for physicians should note both how each individual doctor
(1) moves from one stage to the next or ends the
learning activity, and (2) why he of she took the
action that was undertaken.
The second recommendation relates to documenting clinical change, an outcome of educational activ-
Abort learning activities and return to scanning
for justifiable reasons.
Abort learning activities and return to scanning
for justifiable reasons.
ities. While it is true that only in stage 3 (gaining
experience) can clinical change can be noted, it is
also true that physicians often require multiple exposures to educational interventions before they
enter stage 3 (see Davis and colleagues,21 on the
necessity for multiple educational exposures when
the goal is to change clinical behavior). This means
that the proper evaluation of clinicians’ learning
activities must document the prevalence of movement from one stage to the next (including the
prevalence of doctors ending the learning episode
after stages 1 and 2), as well as summarizing the
evidence that the doctors offered for their actions.
Summary and Conclusions
Physicians’ learning strategies follow four stages
(scanning, evaluating the problem, learning the skills
and knowledge, and gaining experience) that vary
according to whether the problem that precipitating
learning was specific (eg, due to a particular patient)
or general (eg, updating or learning a new body of
skills and knowledge). Specific problems tend to
evolve quickly and make use of learning resources
that are accessible, applicable, and familiar to the
doctor (eg, journals the doctor subscribes to, and
consultants the doctor uses regularly).
In contrast, general problems require more deliberative behavior from the doctor and make use of
learning resources that require planning to access, as
well as those that are readily accessible, applicable,
and familiar. The resources include professional
meetings and materials in the medical library. Learning resource use also varies from stage to stage (more
resources are used in evaluating the problem and
learning skills and knowledge than in gaining experience) and from one variety of problem to another
(eg, learning-resource use is greater for the first two
stages for disease updates than diagnosis or therapy
updates.
Finally, successful interventions to change doctors’
behaviors need to consider both of the stages that the
doctors move through, and the ways in which doctors
will use learning resources at each point.
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Physicians' Learning Strategies*
H. B. Slotnick
Chest 2000;118; 18S-23S
DOI 10.1378/chest.118.2_suppl.18S
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