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Commitment to Change Statements in CME: The Impact of the Natural Learning Actions

Over the past year as I have been building the ‘Natural Learning Actions’ model I have had the opportunity to speak with a whole host of medical educators and learners. One of the areas of medical education research that has consistently come up in these conversations is how a learner’s note taking and reminders might be structured and improved to help extend learning and enable practice change – these are very real, very practical conversations and I look forward to sharing my lessons through the posts on this blog.

From these conversations it has become clear that while there is a general appreciation of the need for our new natural learning action model, there may not be a full appreciation of how much evidence has already been accumulated to support the elements of the model itself. For example, one of the most well-described forms of a ‘learning architecture’ is that of the commitment to change statement. Below is a list of 10 references that provide an evidence-based review of what we now know about the impact of commitment to change statements and the various ways that they may be implemented in practice.

Commitment to change instrument enhances program planning, implementation, and evaluation.

Commitment to change statements can predict actual change in practice.

Effectiveness of commitment contracts in facilitating change in continuing medical education intervention.

Requesting a commitment to change: conditions that produce behavioral or attitudinal commitment.

Effects of a signature on rates of change: a randomized controlled trial involving continuing education and the commitment-to-change model.

Effect of a primary care continuing education program on clinical practice of chronic obstructive pulmonary disease: translating theory into practice.

The impact on medical practice of commitments to change following CME lectures: A randomized controlled trial.

Unanticipated learning outcomes associated with commitment to change in continuing medical education.

Information about barriers to planned change: a randomized controlled trial involving continuing medical education lectures and commitment to change.

Commitment to change statements: a way of understanding how participants use information and skills taught in an educational session.

If you have the time I highly recommend that you read through this body of evidence. Doing so will almost certainly provide some much needed perspective on how note taking and reminders (when effectively structured) can lead to changes in knowledge, attitude, skills, behavior, and outcomes. This is very much the goal of my research and our goal at ArchemedX!

For example:

  • From Wakefield et al we learn that physicians who expressed a commitment to change were significantly more likely to change their actual prescribing for the target medications in the following 6 months
  • From Mazmanian et al and Domino et al we learn that primary care clinicians encouraged to make a commitment to change statement are 3-7 x’s as likely to report a change in practice.
  • From Lockyer et al we learn that providers must take a critical look at commitment to change statements as an “intervention” in their own right and determine how the tool can best be used as a CME intervention.
  • From Dolcourt and Zuckerman we learn that, if learners are given a chance to craft their own commitment to change statements, up to 32% of statement do not correspond to any of the instructional objectives and thus represent unanticipated learning outcomes
  • From Mazmanian et al we learn that a formal signature on a commitment to change statement is less important than making the commitment and being reminded efficiently about the commitment
  • From White et al we learn that commitment to change statements provide planners with meaningful feedback to (1) assess congruence of intended changes in physician behavior with program objectives, (2) document unanticipated learning outcomes, and (3) enable and reinforce intended behavior change.

By sharing these resources I hope that the community can begin to familiarize themselves with how critical the natural learning actions like note taking and setting reminders (the core elements of the commitment to change statement) are to the learning process and I would love to continue the dialog to explore ArcheMedX can help you engineer these solutions. But even more than that, I hope that by (re)introducing you to these data that you will begin to appreciate how successful medical is much more than simply ‘developing and delivering’ content to learners…we must, as a community, help structure the learning experience in ways that simplifies what it means to learn.



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Brian is a research scientist and educational technologist. He helped transform Pfizer’s Medical Education Group and previously served in educational leadership roles at HealthAnswers, Inc.; Acumentis, LLC.; Cephalon; and Wyeth. He taught graduate medical education programs at Arcadia University for 10 years. Dr. McGowan recently authored the book "#socialQI: Simple Solutions for Improving Your Healthcare" and has been invited to speak internationally on the subject of information flow, technology, and learning in healthcare.

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