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Individualized Learning Plans:

A Construct to Promote More

Effective Learning

Ann E. Burke, MD

Associate Professor

March 16, 2011

OBJECTIVES: Participants should

be able to:

�Describe why Individualized Learning Plans

(ILPs) are becoming increasingly important in

medical education.

�Describe the unique needs and attributes of adult

learners.

� Indentify the benefits and challenges of ILPs and

Self-Assessment.

�Describe the various components of ILPs and

how to effectively facilitate an ILP with a learner.

Individualized Learning Plans

�Background-Why the shift to self-directed

learning and ILPs?

�The History-Where did this come from?

�Adult Learners and ILPs: good synergy

�What are the components of ILPs?

�What we know and don’t know about ILPs

�Tips for facilitating ILPs

�Discussion…

Background: Why the Shift?

Background: Why the Shift?

�Broader concepts of CME:

- Continuous Professional Development (CPD)

- Residency training now with emphasis on competency based education

- Life long learning is recognized as crucial (Practice Based Learning and Improvement-PBLI)

- Maintenance of Certification (MOC)

Maintenance of Certification

�American Board of Pediatrics: requires

pediatricians to “assess and enhance

knowledge in areas important to their

practice” for MOC 2

�Royal College of Physicians and Surgeons

requires a variation of ILPs for MOC in

Canada

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Reflective Practice: Moving

away from old notions of CME

�“Rather than assimilating a store of largely

irrelevant information, doctors now need to

develop learning skills which enable them

to sift out and acquire information as and

when the need arises.”

• Parsell G. Contract learning, clinical learning and

clinicians. Postgrad Med J. 1996;72:284-289

Why the Shift?

�Continuous Professional Development

– Not didactic

– More individualized

– Meets needs of adult learners

�CPD: In Practice

– Seeing patients, asking clinical questions

– Searching the literature

– Teaching

Assess

practice

I want

more

details

I have a

question/

problem

Adjust

current

practice

MOC Practice-

based Model for

CPD

MOC 2

Self-assessment

Lifelong Learning

MOC 4

Enhance performance

Optimize outcomes

Model developed by the PediaLink Editorial Board.

The History

Donald Schon- Learning Cycle

�Clinical problem

�Reflection-in-action

�Reflection-on-action

�Improvement in practice

�Level or Zone of expertise

Donald Schon. Educating the Reflective Practitioner. Jossey-Bass Publishers, 1987

Self-Directed, Lifelong Learning

�Important tenet of medical professionalism

�Integral to maintaining professional

competency

– ABIM. Medical professionalism in a new millennium: a

physician charter. Ann Intern Med. 2002;136:243-246.

– Fallat ME, Glover J. Professionalism in pediatrics: statement of

principles. Pediatrics. 2007;120:895

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Self-Directed, Lifelong Learning

�Relationship between clinical experience

and quality of care is NOT straightforward

�Physicians in practice longer than 20 years

have declining knowledge and provide

lower quality of care

Choudry NK, Fletcher RH, Soumerai SB. Systematic review:the

relationship between clinical experience and quality of health

care. Ann Intern Med. 2005; 142:260

Self-Directed, Lifelong Learning

�Theoretically, continued lifelong learning

could prevent deterioration of medical

knowledge & patient care

�Identification of Lifelong Learning as

essential:

– ACGME

– LCME

– ABMS

The History-Where did this

come from?

�Increasing knowledge and information

�Donald Schon: “Practice related learning”

�“Reflective practice”

�Self-directed learning: identifying learning

needs, finding resources to meet those

needs and evaluating their achievement

The History-Where did this

come from?

�“In the practice-learning environment, a

physician will begin an educational activity

not by entering a conference room but by

reflecting on his or her practice

performance.”

Barnes BE. Creating the practice-learning environment:using

information technology to support a new model of CME. Acad

Med. 1999; 73:278-281

White and Gruppen. Self Regulated Learning in Medical Education. ASME. 2007.

Why ILPs: The Adult Learner

�Adults learn best when they are actively

engaged in the learning process and self-

direct their own learning goals and

activities.

– Knowles MS, Holten EF, Swanson RA. The Adult Learner: The

Definitive Classic in Adult Education and Human Resources

Development. 6th Ed. Burlington, Mass: Elsevier; 2005

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The Adult Learner

�Ancient teachers of adults perceived

learning to be a process of active inquiry

�Pedagogic education began to dominate in

Europe in the seventh century

– Monastic Schools and Pedagogy

– Greek words meaning “paid/ped”= “child” and

“agogus”= “leader of”

Adult Learners

�Eduard C. Lindeman’s The Meaning of

Adult Education published in 1926 in the

New Republic laid the foundation for a

systematic theory about adult learners

�“The adult learns to become aware of and

to evaluate his experience”

Adult Learners: Principles

�1. Adults are motivated to learn as they experience needs and interests that learning will satisfy

�2. Adults’ orientation to learning is life-centered; life situations, not subjects

�3. Experience is the richest resource for adults’ learning; therefore the core methodology is analysis of experience

Knowles M. The Adult Learner: A Neglected Species. 4th Ed. 1990.

Adult Learners: Principles

�4. Adults have a deep need to be self-

directing; therefore the role of the teacher

is to engage the learner

�5. Individual differences increase with age;

therefore there must be optimal provision

for differences in style, time, place, etc.

Knowles M. The Adult Learner: A Neglected Species. 4th Ed. 1990.

Adult Learners

�“That is too important to be taught; it must

be learned” - Carl Rogers

�“I’m always ready to learn, although I do

not always like to be taught”

- Winston Churchill

Adult Learners

�“The best way to learn about it,

is to play about it!”

-Mister Rogers

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Learning Contracts

�“Without question the single most potent

tool I have come across in my more than

half-century of experience with adult

education”

Knowles M. The Adult Learner: A Neglected Species. 4th

Ed. 1990:139

Learning Contracts

�“Without question the single most potent

tool I have come across in my more than

half-century of experience with adult

education”

Knowles M. The Adult Learner: A Neglected Species. 4th

Ed. 1990:139

ILP Components in Pediatrics

�Define goals

�Self-assessment

– Personal attributes

– Clinical competency

�Summarize learning needs

�Define learning objectives and strategies to

accomplish them

ILPs: Adult Learning Skills

�ILPs may improve development of self-

directed, lifelong learning skills by actively

engaging learners to take ownership of

their own learning

�Lifelong learning includes learner

identification of learning needs and

determination of how to meet those needs– Hojat M, Nasca TJ, Erdmann JB, et al. An operational measure of physician

lifelong learning: its development, components and preliminary psychometric

data. Med Teach. 2003;25:433

Pediatric ILPs- Goals

�Learning contract

�Self-assessment

�Exercise in self reflection

�Formulated by the individual (resident)

�Guided by teacher…focus on learner

driven needs

�A RC requirement

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Why ILPs

�Getting a commitment in a written form?

– Radiology students with written learning

contracts were more likely to have participated

in CME courses and read instructional

materials in the last 6 months

– Compared with those without written learning

contracts

Renner JJ, Stritter FT, Wong HD. Learning contracts in clinical

education. Radiol technol. 1993; 64:358

Pros and Cons

PROS

�Enhanced awareness of learning needs

�Ownership of learning

�Step towards life long learning

�Ongoing feedback-ideally

Stuart et al. Are Residents Ready for Self-Directed Learning? A Pilot

Program of ILPs in Continuity Clinic. Ambulatory Pediatrics. 2005;

5 (5):298.

Pros and Cons

CONS

�Time limitations

�Coming up with goals can be difficult

�A change…

Stuart et al. Are Residents Ready for Self-Directed Learning? A Pilot

Program of ILPs in Continuity Clinic. Ambulatory Pediatrics. 2005;

5 (5):298

Pros and Cons

“Although the theoretical power of the ILP

approach lies with its emphasis on self-direction

and individualization of learning, both residents

and faculty in our program wanted more

guidance, standardization, and structure.”

Stuart et al. Are Residents Ready for Self-Directed Learning? A Pilot

Program of ILPs in Continuity Clinic. Ambulatory Pediatrics. 2005;

5 (5):298

Pros

�“Lends focus. Stimulating more purposeful

learning”

�“Allows me to re-evaluate learning needs”

�“Allowed my preceptor an opportunity to

know what I want to get out of the clinic”

�“It is good to have regular discussions

about my goals”Stuart et al. Are Residents Ready for Self-Directed Learning? A Pilot

Program of ILPs in Continuity Clinic. Ambulatory Pediatrics. 2005;

5 (5):298

Cons

�“I often don’t know what to work on”

�“Never enough time”

�“Recommendations for specific goals would be helpful”

�“I’m too tired or busy to focus on my goals”

�“Not easy to discuss how learning relates to goals”Stuart et al. Are Residents Ready for Self-Directed Learning? A Pilot Program of ILPs in Continuity Clinic. Ambulatory Pediatrics. 2005; 5 (5):298

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Learning Contracts: Medical

Students

�Viewed as “less useful” than the clinical

experiences

�“As useful” as lectures and seminars

�Utilized a simple form

McDermott M, et al.Use of learning contracts in an office-based

primary care clerkship. Medical Education. 1999;33:374-381

Learning Contracts: Medical

Students

�Primary care clerkship: four weeks

�187 3rd and 4th year students

�Produced 517 “learner-centered goals”

�60% knowledge goals

�37% skill goals

�3% attitudinal goals

McDermott M, et al.Use of learning contracts in an office-based primary

care clerkship. Medical Education. 1999;33:374-381

Requirements

RRC

Requirements

�A Requirement (January 2006) per The

Pediatric RRC

– “Documentation of an individual learning plan

for each resident must occur annually”

Requirements

�“Companion Document” gives some guidance:

�1. Defines ILP

– Documented personal learning objectives

– Strategies to achieve them

�2. AAP Pedialink

– Resident Center

– Program Director Center

ILP Components

�1) Reflection on long-term career goals

�2) Self-assessment of areas of strengths

and weaknesses

�3) Development of plans/strategies to

achieve the goals

�4) Assessment of progress on goals

�5) Revising goals based on achievement

Li ST, Burke AE. Individualized learning plans: basics and beyond. Acad

Peds. 2010;10(5)289

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The Dreyfus Model

Self-Assessment… Self-Assessment

�Poor to modest correlations with other subjective and objective assessments

�Multitude of psychosocial factors are in play when one self-assesses

�Over-assessment and under-assessment are not predictable

�Relative ranking model may increase reliability

Gordon M. A review of the validity and accuracy of self-assessments in health professions training. Acad Med 1991; 66 762-769

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Self-Assessment

�The value appears to be in its ability to force the learner to reflect on their strengths and weaknesses

�Recognize how these strengths and weaknesses may impact learning and performance

Stewart J et al. Clarifying the concepts of confidence and competence to produce appropriate self-evaluation measurement scales. Med Educ 2000; 34:903-909

Self-Assessment

�“ At present our assessment methods stem from

the reductionist philosophy that underpins our

discipline, and we are, thus, trapped by our need

to compare like to like….we will continue to

struggle to measure the unmeasurable, and may

end up measuring the irrelevant because it is

easier.”Snadden D. Portfolios-attempting to measure the unmeasureable?

Medical Education 1999;33:478-479

Study of ILPs

�77% of residents surveyed preferred on-

line submission

�18% have no preference

�5% preferred paper-type ILPs

Jost-Starmer A, Burke AE. Resident Perceptions of Individualized

Learning Plans. Academic Pediatrics 2009.Volume 9, (4) e8-e9.

Study of ILPs

�The most commonly identified barriers

– Competing demands, time

– Balancing lives with residency

– Difficulty with Goal generation

Li ST et al. Successful self-directed learning in medicine: a

conceptual model derived from qualitative analysis of a national

survey of pediatric residents. Acad Med 2010;85:1229

Study of ILPs

�The most common strategies to overcome

barriers:

– Manageable, focused goals

– Establish some sort of tracking system

Li ST et al. Successful self-directed learning in medicine: a

conceptual model derived from qualitative analysis of a national

survey of pediatric residents. Acad Med 2010;85:1229

Study of ILPs: I-SMART

�Important

�Specific

�Measurable

�Accountability

�Realistic

�TimelineLi ST et al. Successful self-directed learning in medicine: a conceptual model

derived from qualitative analysis of a national survey of pediatric residents.

Acad Med 2010;85:1229.

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Facilitation of ILPs

�Do not be too judgemental

�Use Self assessment to highlight abilities

�Actively listen

�Try to encourage I-SMART goals

�Encourage near term and long term goals

�Follow through with timing and follow-up

�Consider maintaining your own ILP

ILPs: Some Suggestions:

�Skill building in self-directed, reflective

learning should be an explicit goal of

working with ILPs

�Offer detailed and user friendly examples

of entries

�Need some dedicated time

Mahatma Gandhi

“Live as if you were to die tomorrow. Learn as if you were to

live forever.”

Discussion…