Most physicians learn through informal approaches, including reading, point-of-care learning, and consulting colleagues. More formal adult learning occurs mainly through continuing medical education (CME). The approach to physician learning through CME is changing and hospitalists are poised to play a crucial role in its development. Hospitalists are increasingly the primary teachers in the hospital setting and play a major role in performance improvement. Modern CME integrates these two processes. In this chapter, we discuss principles of adult learning, the changing landscape of CME, and the resultant responsibilities and opportunities for hospitalists.

Adult learning is complex. Understanding the framework of adult learning theory can help inform curricular design, teaching, and evaluation. Of the many theories of adult learning, three are most influential: the behaviorist, cognitivist, and constructivist theories. No single theory fits the learning style of all adult learners, and most educators use elements from each.

Behaviorism, popularized by B. F. Skinner, focuses on using consequences to shape behavior. A desired behavior is rewarded with positive reinforcement, while undesired behavior is discouraged with negative reinforcement. This theory emphasizes that feedback is critical to learning.

Cognitivism tries to explain learning through information-processing models and minimizes the focus on the behavioral response. It highlights the importance of information that is appropriately organized by the educator and the development of problem-solving skills by the learner.

Constructivism, popularized by Jean Piaget, teaches that learners construct new knowledge from experiences they integrate into their own existing framework of understanding when the experience is consistent with that framework. When the experience is inconsistent with that framework, they either change their perceptions of the experience or reframe their internal model of understanding. This theory emphasizes the educator’s role as facilitator instead of didactic teacher and the learner’s need for a social and active learning process.

Together, these theories suggest that adults learn most effectively when they (1) perceive the relevance of educational material, (2) are actively engaged, (3) have input into choosing educational experiences and directing their own learning, and (4) have the chance to step back and reflect on their learning.

Moore has proposed that adult learning involves a five-stage process.1 These are: “(1) recognizing an opportunity for learning; (2) searching for resources for learning; (3) engaging in learning to address an opportunity for improvement; (4) trying out what was learned; and (5) incorporating what was learned.” Learning occurs not as a linear progression through these stages, but as a dynamic process with complex interactions that include revisiting and concurrence of various stages. CME may stimulate the first stage by providing the recognition that the opportunity for learning exists (“I did not know that continuous positive airway pressure [CPAP] decreases intubation in patients with congestive heart failure [CHF]“) or the third stage by providing the learning needed to address the opportunity for improvement (“I developed the competence to appropriately select candidates for CPAP and the steps to implement it”). As described above, learners most readily progress through stages when they see relevance (“ICU beds are limited and I can save hospital resources by avoiding intubation”), are actively engaged (“The CME presentation used dynamic learning approaches such as case presentations, question and answer, or audience response systems”), have chosen the subject (“I want to learn how to implement CPAP”), and reflect on their learning experience (“Is this something that would work in my institution and do I need more learning to effectively implement this?”).

Recently, an expert panel described the effectiveness of CME based on a systematic review by the Johns Hopkins Evidence-Based Practice Center. The best available evidence suggests that CME is effective in achieving and maintaining knowledge, competence, and procedural skills, as well as improving practice behavior and clinical practice outcomes, if the activity is planned and implemented according to recommended approaches. Assessments show that interventions using live educational strategies are more effective than print, multimedia are more effective than single media, and multiple exposures are more effective than a single exposure. Simulation methods in medical education seem effective in disseminating psychomotor and procedural skills.

While current evidence supports the effectiveness of CME, a systematic review of the reliability and validity of the tools used to assess that effectiveness found that more evidence is needed to confirm their value. Some have pointed out that a rigorous approach to assessment would be best coordinated by a national entity dedicated to providing a concerted approach to examining CME effectiveness.