All about rehabilitation

Rehabilitation Matters

About all rehabilitation

This page concerns developing the competence of the rehabilitation expert in continuing to learn and develop their skills across their professional lifetime, often referred to as Continued Professional Development or Self-Directed Learning. Similar terms used include lifelong and self-regulated learning and the UK General Medical Council refers to it as Research and Scholarship. All professions need this skill to respond and adapt to changes in demands and maintain and increase existing knowledge and skills. It is included in the syllabus because, although its importance is widely acknowledged, I have not found any syllabus mentioning the teaching and training of this skill. Yet, it is a skill that can be taught.

I was once asked to present to the department of psychiatry, where I was a trainee doctor, the evidence on pre-frontal leucotomy as a treatment. This was at St Thomas Hospital, London, where the department arranged many leucotomies and ran large follow-up clinics. I had yet to receive training on finding and collating evidence. I went to a bookshop and bought a book which showed evidence of its ineffectiveness and harm, and I summarised it. This was not well received! A senior trainee was detailed to show me how to find the evidence needed. I realised that I needed to learn how to find evidence and that my seniors were not reviewing the evidence about their treatments.

Table of Contents

Background – professionalism.

In 2001 the Lancet published a series of articles about medical education pointing out the need for change in curricula to reflect the changes occurring in healthcare and society, emphasising teaching professional development. The latter refers to the hidden curriculum: “In the hidden curriculum of medical education are the processes, pressures, and constraints, which fall outside of, or are embedded within, the formal curriculum, and that are often unarticulated or unexplored.” The processes are not specified, but one might have been learning to maintain and improve professional knowledge and skills.

The Royal College of Physicians reviewed what characterises professionalism and gives seven central features, one of which is being a learner and teacher. The report says, “A commitment to lifelong learning underpins the work of all professionals, and the ability to reflect on an event or experience and improve one’s practice defines an effective professional.” It also says, “Lifelong learning includes a commitment to evidence-based practice (while recognising its limitations) and continuous improvement using measurement, reflection and feedback tools.

Richard Cruess and colleagues give a more striking definition. They start with Miller’s pyramid of developing professional competence: knows, knows how, shows how, does otherwise categorised as knowledge, competence, performance, and action. They add a fifth, top category of “is” (a professional), translated into identity. The characteristic is that the person enacts the attitudes, values, and behaviours expected of someone in a professional role. The person thinks, acts, and feels like a physician (or any other professional).

Professionals and self-directed learning

It should not be surprising that professionals must continue learning through life. Societal changes lead to the emergence of new needs the professional is expected to meet and the disappearance of other requirements. The professional must learn new techniques while previously known knowledge is superseded by new knowledge. At the same time, they must maintain other knowledge and skills. This is part of all life, not just professional life. This page is written on a computer, but I learned to write using a dip pen, and we had to make the ink.

Professionally, the development of electronic databases and software such as PubMed and Google have transformed matters since my early training. Nonetheless, I still see or hear people asking for help with diagnosis or management, and I know that five minutes online would give an adequate answer.

The General Medical Council, which regulates all medical professional training, recognises the importance of autonomous research and scholarship. For doctors, it set out a Generic Professional Capabilities framework. Most professions likely have something similar.

The ninth domain is Capabilities in research and scholarship. It would be best to look at the list of required behaviours in 12 main items and five sub-items because they illustrate the broad scope of ‘research and scholarship’. This capability is additional to the existing capabilities given here and here.  The capability encompasses

  1. Continuing Professional Development
  2. Critical Appraisal skills
  3. Self-directed learning, and
  4. A generally broad and curiosity-based approach to clinical practice.

Doctors in training recognise the need to learn self-directed learning skills.  Melissa Nothnagle and her colleagues interviewed 13 final-year residents in the US and found that medical trainees:

  1. understand and value the concept of self-directed learning but undertook limited goal setting and reflection;
  2. reported a lack of skills to manage their learning, particularly in the clinical setting;
  3. still valued traditional, teacher-centred approaches even though they were supposedly in a learner-centred culture;
  4. recognised patient care as the most potent stimulus for learning but often perceived patient care and learning as competing priorities;
  5. wanted guidance and training in self-directed learning.

Thus learning to learn and how to answer questions adequately and quickly is vital. During post-graduate training, professionals become familiar with educational events such as local teaching sessions, grand rounds, seminars, and conferences. Most of these are relatively passive. I suspect that training in self-directed learning is rare. A Google search for courses on self-directed learning only revealed self-directed learning resources on self-directed learning, a somewhat circular phenomenon!

This is a practical skill and can only be acquired through regular use. It cannot be learned as factual knowledge. The professional must practise and use the skill to improve – precisely as our patients learn best from task-specific practice.

Capability and competency

The overall capability, adapted from the General Medical Council’s Good Medical Practice, is “to develop and maintain your professional performance, applying your knowledge, skills, and experience to your professional practice.

The competency in the syllabus concerns self-directed learning, which is only a part of the overall capability. It should be relevant in most work areas, easily practised daily, and has a measurable outcome. In the Rehabilitation Medicine syllabus, it is described thus: “During daily professional work, can identify a piece of information needed to improve professional performance, and to find a sufficient answer within 15 minutes.”

The indicative behaviours, knowledge, and skills are shown in this document, which also gives most of the articles referred to on this page.

Models of learning.

Research and scholarship highlights the central activities needed to continue learning; research implies looking for new information, and scholarship implies learning at a high level, being a specialist. Knowing the theoretical models concerned with self-directed learning may identify where to concentrate one’s attention to help improve the skill. There are several theories and models, but generally, they are similar.

Sawatsky and colleagues put forward one derived from a qualitative study involving internal medicine trainees. The theoretical basis behind the analysis was a three-factor model encompassing context, personal factors, and the learning process.

Contextual features fell into three groups. One was the availability of guidance that imposed some structure upon the learning. Examples included a curriculum, examinations, peers, more senior doctors, and patients. Closely related to this was the structure and culture of the training programme, such as having time to undertake the activity and the culture or expectation of learning by the trainees.

The context also provided most of the barriers. There was tension in allocating time between patient care, attendance at obligatory teaching or research commitments, leisure and non-work activities, and self-directed learning. A perceived lack of time was frequently mentioned as an obstacle.

Personal factors fell into four groups. Motivation and motivating factors were important. For example, low motivation was associated with a lack of autonomy in making patient decisions and unrealistic expectations of achievement. In contrast, previous success and self-confidence were associated with higher motivation. Some residents (trainees) were also motivated to avoid “looking stupid”.

The second personal group was an acknowledgement that the approach of a trainee developed and changed with experience and as the nature of the work changed. For example, textbooks were used more frequently in the early stage of training. The level of knowledge learned altered as the trainee acquired more basic knowledge. The personality and learning styles of the trainee were also important.

The fourth personal factor is linked directly to the process. The trainee’s level of knowledge determines the new expertise needed because self-directed learning is triggered by a mismatch between the trainee’s ability and what is required.  For example, when involved with a patient who has had a stroke, someone familiar with stroke might be triggered to investigate how to rehabilitate someone with prosopagnosia, a rare condition. In contrast, a novice might investigate the expected recovery over the first six months.

The process is necessarily triggered when someone realises they do not know or understand something they should. However, there is a second, more powerful trigger – curiosity. The person learned they lack knowledge and wish to discover to satisfy their interest even if there is no apparent need to know clinically.

The person’s vital first step is to:

  • Realise that there is something they do not know that might be knowable, and
  • Be sufficiently curious or concerned to do something about it

The remainder of the process is reasonably straightforward. The person will:

  1. Formulate some objectives, what they wish to discover and learn;
  2. Identify and use some appropriate resources to achieve an answer;
  3. Use the knowledge either in the triggering situation or in a similar case;
  4. Check that they have reached the learning aimed for.

Influences on self-directed learning.

There are many studies on what influences self-directed learning.

Jeong and colleagues undertook a scoping review on what facilitates or inhibits self-directed learning in physicians; 17 articles were included. They used the Theoretical Domains Framework to analyse the data; this framework outlines factors that influence the use of evidence in clinical practice.

They found that four domains (of 13) had the most influence. The environmental context and resources were, unsurprisingly, the most powerful. This referred to having time available and having access to appropriate resources to find and access the information needed. Structured tools to appraise the new information and reflect upon it were significant facilitators.

The social context was a second strong influence. Increased self-directed learning was associated with physicians who engaged in teamwork, collaborative working, interacting with others and networking. In contrast, they found medicine’s “on-the-job learning” culture was a barrier.

The third domain was the physician’s belief in the online programmes used. This only influenced a part of self-directed learning, choosing a specific online programme. The last field, behavioural regulation, is environmental because it concerns the presence of support.

Thus Jeong et al. highlighted the vital role of context, and Joris Berkhout and colleagues investigated this in more detail. They usefully state that “context includes what people do in a context, the roles that people have in a context, interpersonal relationships, and the physical context in which learners learn.

Their context description implies that it is not a static descriptor of where someone is. Instead, context is dynamic and varies; it arises from interactions and does not solely describe the surroundings. They argue that learning in healthcare professions must be integrated into daily clinical practice to ensure its relevance and integration of learning into daily activity.

There are many theories related to self-directed learning. Berkhout et al. also list and describe the fundamental theories behind self-regulated learning as theories covering achievement goals, a constructivist approach to learning, self-determination, situated learning, workplace affordances, and self-regulated learning.

Improving self-directed learning.

If self-directed learning is more effective than other methods, revealed later, it is worth understanding how it can be improved.

van Houten-Schat and her colleagues reviewed the evidence on teaching self-regulated learning (another synonym). From the 18 studies examined, they identified the typical individual, contextual, and social factors influencing self-regulated learning. They concluded that most teaching focussed on goal setting and monitoring progress, and none taught self-evaluation. They recommended that education pay more attention to reflection and enable students to use their skills, albeit with support.

Piet van der Keylen and colleagues systematically reviewed studies of the information need of family doctors to identify their needs and factors that hindered them from being met. They identified five main groups of requirements.

Individual needs.
These were personal needs identified, including the need for continuing medical information and keeping up-to-date; a frequent lack of skill in using the internet and a need to learn (the search covered all years, but most studies were published after 2000); working collaboratively was a valued activity; understanding evidence-based medicine and how to evaluate and interpret evidence; and a preference for paper-based materials.

Access.
The access needs included adequate time, easy-to-use internet resources, cost (paying significant amounts was a large barrier), language  (being in a language known to the doctor), and other technical issues.

Quality needs.
These included: knowing that the source was trustworthy and the results credible, concise presentation of information, for example, informative summaries, satisfying the specific need of the searcher, and being up-to-date.

Utilisation needs.
These covered three somewhat separate issues. The first was that the interface should allow easy navigation with well-organised information. The second was a large gap between what was researched and published and the essential information that family doctors needed. Last, if a doctor searched during a clinical encounter, the search needed to improve the doctor-patient relationship.

Implication needs.
The primary need in this group was for information to be relevant to daily clinical practice. In addition, the information required to help educate patients about their condition should justify their clinical practice and decisions, which suggests an uncritical approach to clinical practice.

birds on river Thames at sunset

Effects of active learning.

So, when compared to traditional learning methods, does active learning have an effect, and if so, how much and to what?

Nicolette Harris and Cailee Welch Bacon systematically reviewed the effects of active learning in healthcare professions, identifying 154 studies. They concluded that there was sufficient evidence to warrant Grade A recommendations that active learning techniques were associated with more improvement in lower-order and higher-order cognitive skills compared to passive learning techniques. Nevertheless, they cautioned that extensive high-quality studies were still needed to investigate whether this translates into clinical practice and work performance.

I know of three systematic reviews of problem-based learning. The first, in 2002, found six controlled studies; there was insufficient evidence to draw any firm conclusion of effectiveness compared to more traditional teaching methods. The second, in 2014, found 15 studies involving post-graduate doctors, and there was only limited evidence that problem-based learning enhanced professional performance and health outcomes.

The third, in 2022, focused on problem-based learning in medical undergraduates and found 124 relevant publications, but many were small or of low quality. Nevertheless, the evidence showed that this method increased knowledge retention and academic performance as effectively as traditional teaching. Additionally, it significantly improved social and communication skills more effectively than conventional teaching.

Implications for training.

Much of the evidence above comes from studies of medical training, probably because medical training is subject to the most scrutiny. Still, there is no reason to think that other healthcare professions are different, and the evidence should apply to all healthcare professions. Some practical consequences are set out here, not in any specific order.

Whatever your profession, you must realise that continuous learning is essential, not a luxury, and allocate time to it in your daily work. This competency emphasises two skills when learning. First, you are aiming for something other than perfection; you should aim for a slight increase to be better than before. Second, you should spend at most 15 minutes on the activity; this activity can fit into most working days at some point.

Associated with this “good enough” approach, you need to avoid being over-ambitious in what you try to learn. You should set achievable learning targets, such as knowing two effective drugs for controlling neuropathic pain. Learning one thing well is better than having incomplete, patchy knowledge about many things.

You must understand that every day you will encounter things you do not know and could find out. The challenge is not trying to find something to learn but choosing one of the many arising each day. It would be best if you either chose whichever one interests you most or the one that is clinically crucial to you and your patient. These are more likely to motivate you, with curiosity being a vital driver.

You will need to temper curiosity a little to ensure you cover essential areas of knowledge, for example, required for an examination or to follow advice from a guideline. Even then, it is better to be curious about a policy, wondering if the evidence supports the recommendation or if there are more risks than acknowledged.

It would be best if you fostered a local culture of curiosity and self-directed learning among your peers, team members, and colleagues. This can be done, for example, in team meetings or when discussing a clinical problem. It is worth remembering that a culture of teamwork and collaborative working and behaviours such as interacting and networking with others is associated with better learning. You should foster that type of environment.

Last, it would be best if you remembered that the benefits of self-directed learning extend well beyond learning more facts. It improves your social interactions and your communication with others. It also fosters and increases your professionalism so that you and others will recognise that you are indeed a rehabilitation professional.

Conclusion

While I have stated that failure to achieve any single competency cannot be considered evidence of a general inability to reach an entrusted capability, this competency is an exception. Without this competency, a person will have difficulty achieving professionalism in their profession or rehabilitation. It also makes life much more interesting by giving a short break from patient demands, which will benefit all patients.

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