Are We Gaining Something With Education That Reinforces Current Knowledge and Behavior?

By Katie Stringer Lucero, MS, PhD, and Stephen Dunn, Medscape Education Global, New York City/London

Who works in a field where there’s a fast pace of new information? If you’re in healthcare, you're probably saying, "I do!"

In a survey of 2013 practicing physicians from around the world, 48% of them made a practice change in the last week or month. Of the 1706 who had made a practice change in the past year, 34% said the source of that change was continuing medical education (CME) (21% online, 13% live) and 30% said medical journals (Figure 1). From this survey, we know that practice change happens often for physicians and that the sources of information leading to that change are varied but are primarily CME and medical journals. So, what is the evolution of a practice change?

Lucero graphic.png

Figure 1. Sources of Information for Practice Changes 

Most would argue that in the absence of a supervisor directing someone to do something a certain way—or believing that doing something in that way could lead to adverse events—hearing something just once is unlikely to lead to a lasting practice change. However, repeated exposure to the knowledge related to that desired practice through multiple sources of information and methods of dissemination (eg, word of mouth, text, audio, etc), drives change.[i] Behavior change theorists and researchers suggest that one needs motivation and confidence to enact new knowledge.[ii],[iii] How, then, does one get motivated and confident? We maintain that reinforcement, or confirmation of what one knows, is an important part of behavior change. In fact, in the same survey mentioned previously, 29% recalled they experienced reinforcement that they were already following best practices from their most recent participation in online CME. Of those who experienced reinforcement, 48% gained more confidence in their current practice. This supports the notion that reinforcement of a topic is an important component of behavioural change.

Imagine a rapidly developing disease area, such as non-small cell lung cancer (NSCLC) that constantly evolves with new actionable sequence variation and new tests available to determine appropriate treatment selection. For the busy lung cancer-treating physician who uses CME to keep up to date with the latest developments in their field, validating or reinforcing that their current knowledge or practice is indicative of best practice is an important outcome by which to measure their participation in that CME activity.

To further examine the value of reinforcement in CME, we asked over 20,000 healthcare providers, including 6105 physicians who participated in 1 of 6 online Medscape activities covering topics such as pregnancy, genetic testing, hypoglycemia, cardiovascular health, and oncology in October and November 2019, "Did you experience reinforcement of your current practice(s) from this activity?" If they answered "yes," we asked them, "To what extent do you agree that reinforcement of current practice(s) through education is important to your use of evidence-based practices?" They responded on a Likert-type scale where 1 = "disagree" and 5 =  "agree."

87% of physicians said they had experienced reinforcement, and 65% agreed and 25% somewhat agreed that reinforcement is important in their use of evidence-based practices. There was variation by specialty (Table 2). The results suggest that reinforcement is most important in the practices of neurologists, diabetologists and endocrinologists, oncologists, pulmonologists, pathologists, cardiologists, and primary care physicians, with two-thirds or more agreeing that reinforcement through education is important in their use of evidence-based practices.

These results are in alignment with published literature, which indicates that reinforcement is important for behavior change. Haleem and colleagues[iv] conducted a study on adolescent oral health education, which found that one-time education did not improve behavior significantly; however, repetition and reinforcement of the education resulted in significant improvement at the 6-month follow up, with sustained impact at 12-month follow up. In addition, behavior change associated with oral health was sustained in those who had reinforcement through repetition of information over the course of different learning sessions—spaced repetition—which is better for memory retention and supports the need for a variety of information sources (live, online, different faculty) or activities that cover the same topic.

The findings from both our survey research and the published literature support the importance of reinforcement through education for behavior change. Thus, not only should education be designed so that it does the following:

  • Introduces new information and reinforces related information
  • Examines reinforcement as a part of the outcomes study design
  • Assesses confidence improvements for those who experience reinforcement would also be an important outcome

Outcomes assessment should be designed to allow for identification and delineation of those who experience reinforcement, as well as improvement in what they know, and if appropriate, other outcomes such as confidence and behavior change. 

Table 1. Specialty Differences in Perceptions of Reinforcement

 

N

% who experienced reinforcement

% who agree reinforcement is important

% who somewhat agree reinforcement is important

Neurologists

122

87%

80%

15%

Diabetologists and endocrinologists

135

83%

72%

23%

Hematology/oncology specialists

178

96%

70%

26%

Pulmonologists

66

95%

70%

18%

Pathologists

109

82%

69%

23%

Cardiologists

295

93%

68%

23%

Primary care physicians

2755

91%

67%

24%

Orthopedists and orthopedic surgeons

66

85%

64%

30%

Other specialists

94

81%

64%

31%

Emergency medicine physicians

185

89%

63%

20%

Radiologists

211

91%

62%

27%

Obstetricians and gynecologists

420

86%

61%

26%

Public health and preventive medicine specialists

110

74%

60%

28%

Pediatricians

276

71%

59%

32%

Psychiatrists

473

73%

56%

33%

Surgeons

152

79%

53%

21%

Gastroenterologists

41

94%

52%

29%

Plastic surgery and aesthetic medicine

46

91%

52%

36%

Anesthesiologists

173

85%

50%

33%

 

________________

[i] Brown PC, Roediger III HL, McDaniel MA. Make It Stick: The Science of Successful Learning. Belknap Press;2014. 

[ii] Bandura A. Self-Efficacy. The Corsini Encyclopedia of Psychology. 3rd ed. Hoboken, NJ: Wiley;2010. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1002/9780470479216.corpsy0836  Accessed on: February 20, 2020. 

[iii] Oyserman  D, Destin M. Identity-based motivation: Implications for intervention. Couns Psychol. 2010;38:1001-1043. 

[iv] Haleem A, Khan, MK, Sufia, S, et al. The role of repetition and reinforcement in school-based oral health education—a cluster randomized controlled trial. BMC Public Health. 2015;16. Available at:


https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2676-3  Accessed on: February 20, 2020.

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