Learning Transfer
Once again, lets return to the purpose of CME in general: To enhance physician performance and positively impact patient outcomes. While, learning for learning's sake is of course laudible, in the professional setting it must be transferred into use to be efficient and effective. As Sophocles notes in Oedipus Rex:
How terrible is wisdom when it brings no profit to the wise
So transfer is an old idea. More recently (1916 to be precise), John Dewey noted its importance in the relationship between educational stimuli and adjustment of behavior, and Alfred Whitehead (in 1929) cautioned that teaching "inert ideas", those not utilized and tested in combination, is not only useless but also harmless, and teaching fewer ideas in multiple contexts is more likely to achieve the goal of having those ideas used in, and adapted to, appropriate contexts.
Bransford Brown and Cocking in their seminal work echoed the idea:
Transfer is affected by the degree to which people learn with understanding rather than merely memorize sets of facts or follow a fixed set of procedures....attempts to cover too many topics too quickly may hinder learning and subsequent transfer
Yet as late as 2007, broad statistics across multiple industry settings estimate that a mere "10% of the billions of dollars invested in training is claimed to translate to job performance - some of the blame for this depressing statistic is down to design.
Transfer may be defined as the effective and continuing application of knowledge, skills, and attitudes learned/acquired from training on the job, generalization, and subsequent maintenance of these over a certain period of time (Baldwin & Ford, 1988; Broad, 1997; Ford & Weissbein, 1997; Xiao, 1996)
Dewey, John. Democracy and Education. New York: The Free Press.1996. (Fisrt published in 1916).
Wiggins, Grant, & McTighe, Jay. Understanding By Design. Upper Saddle River: Pearson/Merrill Prentice Hall. 2006.
Bransford, John, Brown, Ann L., & Cocking, Rodney R (2000). How People Learn: Brain, Mind, Experience, and School. Washington DC: National Academy Press.
Considerations for Enhancing Transfer
- Participants come to an activity with preconceptions about how the world works. If their initial understanding is not engaged, they may fail to grasp new concepts and information that are taught, or they may learn them for purposes of a test but revert to their preconceptions in the outside world.
- To develop competence in an area of inquiry, participants must:
- Have a deep foundation of factual knowledge;
- Understand facts and ideas in the context of a conceptual framework; and
- Organize knowledge in ways that facilitate retrieval and application
- A “metacognitive” approach to instruction can help participants learn to take control of their own learning by defining learning goals and monitoring their progress in achieving them
Evidence supports use of discussion to foster metacognition in the college classroom9. By observing and engaging in questioning, participants become better at monitoring and questioning their own thinking.
A critical aspect of education in the medical environment (and key in all other learning environments also) is to prepare participants for flexible adaptation to new problems and settings, i.e. cultivate their ability to transfer their knowledge to new problems. This transfer of learning rests on some key principles:
- Initial learning is necessary for transfer
- Knowledge that is overly contextualized can reduce transfer
- Transfer is best viewed as an active, dynamic process
- All new learning involves transfer based on previous learning
Critical features of learning that affect participants' ability to transfer what they have learned include:
- The amount and kind of learning is important in shaping the development of expertise
- Participants are motivated to spend time solving problems that they find interesting
- Participants are motivated by opportunities to use knowledge to benefit themselves and others
And here we circle back around to assessment to improve a program, as instructional differences are made more apparent when evaluated from the perspective of how well the learning transfers to new problems and settings. In continuing medical education, this is can be identified through adherence to guidelines and other performance measures that can be evaluated with the use of the EHR3.
Metacognition refers to people’s abilities to predict their performance on various tasks…and to monitor their current levels of mastery and understanding3. Teaching practices congruent with a metacognitive approach to learning focus on sense-making, self-assessment, and reflection on what worked/needs improving. This increases the degree to which participants transfer their learning to new settings and events.
Such an approach helps participants take control of their learning and supports transfer. Reciprocal teaching is an example of this approach.
Barriers to Transfer
We noted previously that covering too much content is a significant barrier to transfer. Broad and Newstrom identified additional sources of barriers in their research on workplace training:
- Lack of Enforcement on the Job
- Interference from Immediate Work Environment
- Non-Supportive Organizational Culture
- Trainees Perception of Impractical Training Programs
- Trainees Perception of Irrelevant Training Content
- Trainees Discomfort with Change and Associated Effort
- Separation from Inspiration or Support of the Trainer
- Trainees Perception of Poorly Designed/Delivered Training
- Pressure from Peers to Resist Changes
They concluded that just one of these (#4) is the primary responsibility of the learner. The educator must ensure that the participants perceives that the training is relevant and practical (#4 and #5), and that the activity is well designed (#8). Secondarily, the educator must also realize that all change efforts meet resistance (#6) and the education that ends at the door often proves ineffective (#7).
Understanding these barriers can help the educator design activities that mitigate them and promote driving forces for change. Broad and Newstrom use Kurt Lewin's change model as a basis for mitigating barriers. They also a present a model for making decisions about training needs. This might look familiar:
