Designing CME for Behavior Change: Sarah Atwood on Learning Science in Action

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If you're a CME writer or work on the content development side of continuing education, chances are you've been here before. You've created content packed with evidence and polished slides. But deep down you wonder, will this actually change how clinicians think or practice? You might feel boxed in by the same default formats you've been using forever, hoping they'll somehow drive behavior change.

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What you really want is to design CME that sparks action, education, that clinicians remember. Apply and that ultimately improves patient outcomes. The struggle is that the leap from knowledge to practice isn't always obvious, and the tools to bridge that gap can feel a little bit out of reach, and that's where today's conversation comes in.

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Welcome to Write Medicine. I'm your host, Alex Howson, and today we're getting the learning design skinny from Sarah Atwood, director of Learning Design at Medscape, where [00:01:00] she leads a team dedicated to advancing both clinician and patient education. With a background in communications, Spanish and a master's in public health.

[00:01:10] Sarah has built her career at the intersection of behavior science, curriculum design, and healthcare education. For more than seven years at Medscape, she has focused on medical simulations, patient education, and aligning clinician and patient learning to improve outcomes. Her work blends applied learning science with a human centered approach.

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Sarah must be one of the relatively few people in CME who actually has a background in learning design and healthcare education.

[00:01:47] So I asked her to explain to us some of the different terms we hear in continuing education, like learning design, curriculum design, design thinking, instructional design. What are these different [00:02:00] things and why should we care about any of them at all?

[00:02:03] Sarah Atwood

We should care about them because we care how people change, right? And we care how people learn. In terms of the definitions, like there are some nuances between the different terms. Instruction is often focused on applied learning science. Which is also the focus of learning design.

[00:02:22] Learning design historically sometimes has involved like an emphasis on the learning experience, while a traditional term of instructional design is focused more on like the design and delivery of the content. To me they're one and the same. I think strong instructional design should be human-centered, should be learner-centered, should focus on the instruction and the experience, and both are systematic. And so yeah, both are, focused on that applied learning science.

[00:02:52] Alex: Let's talk about learning science because in CME, you know, traditionally people have talked about adult learning principles and

[00:03:00] kind of reduce them to, you know, five principles that people can sort of routinely trot out if you push them.

[00:03:07] But learning science is much broader. What are the kind of key principles of applied learning science that you think are particularly important in the work that we do in continuing education for healthcare professionals?

[00:03:21] Sarah Atwood

A set that may be newer to folks is mayor's multimedia principles. The 12 multimedia principles built on learning science of dual coding theory and cognitive load theory. A lot of people are familiar with cognitive load, but guides the design of instruction using multimedia. And it's operationalizes those theories in a way that is really concrete. And yeah, highly recommend that folks look into those principles. That's one kind of set of principles that I think. Would be valuable for people [00:04:00] to know more about or apply more consistently. And it helps people think about the value of adding graphics with words, right? Or spoken words with visuals or like really thinking about cognitive load and our memory and removing extraneous images or words or, like really focused on the cognitive load. Another aspect of learning science that comes to mind is just this idea of learning for transfer. So focus not just on the gaining of knowledge. And I know as a industry, we, I think there is a lot of focus on real world outcomes, right? But in practice, I think sometimes it's hard for folks to really think about okay, what is the application of the activity we're creating or the program that we're creating? And we want it to stick and we want it to be applicable. And so with the adult learning principles, there is a lot of making sure it's learning centered and making sure it's realistic and it's applicable.

[00:04:57] And there's a lot in learning science [00:05:00] around behavior change that I think that's where some of my interest in the public health and my public health background comes into. And I've seen it in some of your work on WriteCME in terms of a focus on stages of change and the trans theoretical model. I think that is a really key piece for to be thinking about in terms of learning science and behavior change and how we're designing learnings.

[00:05:26] Alex

There's a lot to dig into there. And if you do have a particular resource that we can direct people to on mayor's multimedia principles, I'll make sure to put a link in the show notes there.

[00:05:36] You mentioned transfer. I mean, I was an academic way back in the nineties and we were definitely talking about transfer then.

[00:05:43] It seems that we've really moved away in CME from that language to applicability and learning change and behavior change. So if we could dig into those two things a little bit. Do you see. Differences [00:06:00] between learning change and behavior change?

[00:06:02] Maybe I should give more context to the question and, and where it it comes from because, you know, when we're thinking about assessment and evaluation in CME of course behavior changes the holy grail for most people. But when you look at, you know, the predominant 15 minute, 30 minutes, 60 minutes, education activity is not necessarily gonna be able to create the kind of behavior change that

[00:06:28] many people are seeking, many educators are seeking. And so it seems to me that learning change is an intermediary step between what's happening now and the long-term behavior change that we want to see in healthcare professionals, especially when we've documented really significant clinical practice and performance gaps.

[00:06:47] So maybe that learning change is okay, we can look at that and see what are the additional layers that we need in order to get to that behavior change, I guess is how I think about it. And I [00:07:00] was wondering if, if that's something that informs what you do in practice.

[00:07:04] Sarah Atwood

Yes, absolutely. I think that's where the stages of change came up for me.

[00:07:08] Is thinking about yeah the incremental steps that can feel incremental but are huge and thinking about behavior change and that an activity may ultimately be getting at a aspect that influences patient outcomes, but based on where the learners are, it may be more focused on attitude adjustment, right? Or thinking about what gap really are we trying to focus on in the root cause?

[00:07:40] And then thinking about is it knowledge, is it competency, is it performance? And if we go straight to that behavior change performance, we might be missing the 75% of folks who really are just weighing the pros and cons of making a change. Or, have some particular barrier to care to treatment, to [00:08:00] access to, whatever the topic may be.

[00:08:02] Alex: They're in that contemplative stage. Yeah,

[00:08:05] Sarah Atwood: Yeah.

[00:08:06] Alex

I know that Medscape are big stages of change. Users have been for a long time, but I'm not sure that a lot of other education providers in our field are necessarily formally applying a stages of change model.

[00:08:21] What makes your approach to stages of change effective? How do you get that picture of where learners are in order to start building your education approaches?

[00:08:34] Sarah Atwood

Medscape has, and probably other providers do too, but like a wealth of information from other activities that incorporate surveys that incorporate, confidence, commitment to change, like all these other kind of questions that help us gather data relevant to, I think there's some questions in some of our assessments about barriers, that would, that help us better understand the [00:09:00] learners and yeah, where they may be in the stage of change.

[00:09:04] Alex

I think what you've just described there is probably pretty common in, in the sense of, you know, we're all looking for barriers and facilitators and trying to figure out. Okay, we see this gap. Why does it happen? And of course you mentioned root cause analysis. That's another pendulum thing.

[00:09:18] It seems like about a decade ago, we were talking a lot about root cause analysis and then it slipped off the radar a little bit and now it's come back and everyone's talking about RCA. And that's certainly a technique that, I think can be really helpful in drilling down to get that information about stages of change and as, and you mentioned attitudinal adjustments,

[00:09:41] That's one of the values of root cause analysis, I think, is that you can really dig into. Those attitudes and and belief systems and values in a way that a conventional needs assessment doesn't necessarily tap into. And that certainly gives you a lot of data for thinking [00:10:00] about where people are in their, in their stages of change.

[00:10:03] Sarah Atwood

Onto that too, like stakeholder involvement, right? If you're co-creating with faculty, with patients, with, subject matter experts who have insight into the target audience and in reality and in practice what they're seeing in terms of all of those, I think that partnership and stakeholder engagement can be really useful in terms of better understanding the landscape there.

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[00:11:29] Alex

Well, let's talk about co-creation because one of the things that you focus on increasingly is you're focusing on clinician learning, but also patient facing learning. Talk a little bit if you would, about the, work that you're doing in relation to patient facing education or education with clinicians about how to engage with patients.

[00:11:53] Sarah Atwood

One of my favorite subjects.

[00:11:54] When we're thinking about patient outcomes, right? Who's part of the healthcare team, we think about the healthcare [00:12:00] team being the clinicians and the I would argue the healthcare team is always, always includes the patient and the caregiver the family members.

[00:12:09] And so when we're thinking about the healthcare team, the education that we are offering to the entire healthcare team, being clinicians and or patients and the alignment there is super valuable, regardless of the topic.

So when we focus on a healthcare gap oftentimes there are different aspects is that patient education gap, clinician gap. Focus on the healthcare team, and the alignment between the education. So an example that I worked on recently, we have at Medscape, we have lots of different patient education. So we have standalone patient education that could be podcasts or surveys or, whiteboard animations, lots of different offerings that are really targeted.

[00:12:52] That are patient and caregiver focused. And this can be aligned with clinician education and more and more they are really [00:13:00] hyper-focused and aligned, which is exciting and fun. We have patient handouts which are attached to clinician education, which I find those really valuable.

[00:13:09] Like one that I worked on recently was on postpartum depression. And so the clinician activity was all about diagnosing postpartum depression and some treatment options the evidence-based treatments and the patient handout that clinicians could give their patients focused on diagnosis of postpartum depression, but also like key questions to ask your clinician in thinking about treatment, like yes, medication treatment, but also more holistic treatment support resources. our team, like in all the patient education that we designed is really focused on the shared decision making, whether it's the patient or the caregiver, both. How do we participate fully, show up fully in our own care engage with the clinicians, ask the right questions.

[00:13:59] And I think [00:14:00] in the same breath, our clinician education has a pretty strong focus also on shared decision making, ensuring that the care is centered that we're thinking about patients and caregivers as part of the healthcare team in the decision making. in our learning design, a lot of the action based summaries that we have are focused on shared decision making, approaches for particular which is fun to see, acknowledging some of the barriers or thinking about, just really having a patient centered orientation to the gap in the learning.

[00:14:35] Alex

I'm assuming that you have a lot of partnerships with patient advocacy organizations and foundations and such. What kind of response do you get from them in terms of participating in this kind of education?

[00:14:48] Sarah Atwood

Our work with our partners is I find it so super rewarding. I love when an activity comes through that has a partner organization they're super receptive, I think. Realistically involvement [00:15:00] of partners can look different, depending on funding and availability and and whatnot.

[00:15:05] I think if the ability is there, having partners involved in needs assessment and the design, we talked about co-creation like in the beginning, that is a checkbox of saying, yay, we included the patient voice. But like really meaningfully including perspectives and lived experience, helping ensure that it's relatable.

[00:15:24] And I can think of multiple examples both on our meds sims, our simulation side, where we've involved partners engaged partners and our patient education offerings. Like we did one on PTSD. One, a major depressive disorder, like the partners involved in that work really lend that lived experience in a way that, you just don't necessarily feel on a needs assessment. subject matter experts are amazing, in helping provide that lived experience. And I think we can think more broadly about subject matter experts in not just including [00:16:00] faculty, but including patients and caregivers as a subject matter experts.

[00:16:05] Alex

A lot of our listeners are writers and writing. In the voice of lived experience can sometimes be challenging, especially if you come from a scientific or a clinical background where you're very much focused on a little bit of distance from the text as it were.

[00:16:20] Do you see things in practice that writers can think about when they are involved in that co-creation of content that does have a deep lived experience component to it?

[00:16:32] Sarah Atwood: Focused on education or clinician education both.

[00:16:37] Alex

I think we forget that the clinician also has a lived experience that is not just about clinical decision making. There's emotional regulation, there's workflow, there's team dynamics, all of those things to consider.

[00:16:52] Sarah Atwood

I know you and I spoke a little bit about Addie, right? Like in thinking about instructional design and how you approach the design of education, [00:17:00] of curriculum, of an activity. I'm thinking about really who is your target audience and who is that human?

[00:17:07] And what may be the gap, like the aspect of the gap that they're feeling or that would resonate with them. What are they considering when they're weighing the pros and cons of making a change? about the needs assessment from that human centered perspective I think can help maybe the rider doesn't have that lived experience themself that can. empathy, with the,

[00:17:29] Alex: Yes.

[00:17:30] Sarah Atwood: In that way, , I found a lot of the patient advocacy organizations, like they're fabulous videos and right, like all sorts of materials out there to really better understand people's stories and from clinicians too. Clinicians, as you said, are humans. There's lots of emotion as we know that goes into learning and behavior change. And so really trying to understand the human-centered lived experience. But I do think it is helpful to think about again, that like the gap in the root [00:18:00] cause and trying to narrow down a little bit on, okay, what is the specific thing that I'm trying to address. And within that context, in terms of creating education that will feel relevant for someone, what will it be that will help people see their own gap that will help them reflect on their own gap? That will make it relatable.

[00:18:21] And I think that just trying to build the empathy, when we're thinking about the initial aspect of our design is really useful.

[00:18:28] Alex: Yeah, you have to find a point of connection, don't you,In that design process.

[00:18:32] Let's talk about learning styles because people still talk about these, what are they and why should we be talking about something else?

[00:18:43] Sarah Atwood

Yeah, it's fascinating. Like learning styles are still in, they're everywhere. And it makes sense to a lot of people. I think that's, I think that's why they're still out there, right? Is it makes sense to people that. That we should be thinking about the human the [00:19:00] different, like differentiating learning meaning the learner where they are.

[00:19:03] And so people think oh yeah, learning styles, that makes sense. We know that it's not backed by evidence. So learning styles, meaning I'm an audio, I'm a visual learner. I learn best by doing the reality is that tailoring, learning towards a preferred style doesn't improve outcomes.

[00:19:19] And that's what we're in the business of, improving outcomes, that's what we do. And they can actually limit learners. So when I mentioned mayor's, multimedia principles or dual coding or these strategies that are evidence-based that are in the literature, that are evidence informed that work and practice are not about matching style.

[00:19:38] It's about enhancing the understanding and thinking about our brains learn. And so really relying on the learning science in that way, so the learning science does back up that if you are reading words and you see a graphic

[00:19:54] That reinforces the material. Yeah, that is gonna help it

[00:19:57] Alex: Yeah.

[00:19:58] Sarah Atwood: That's gonna make it stickier. And so that [00:20:00] is really valuable. Someone who is thinking about learning styles might be like, oh yeah, I saw a visual and I'm a visual learner. And that's why it was relevant for me, or most learning.

[00:20:10] I just actually had this. Conversation with a family member. I was talking to 'em about learning styles and were like, oh, I learned best by doing. It's like we all learn best by doing. it's depending on what the goal is, what the desired outcome is. Like we all need practice. We all need a chance to pause and reflect.

[00:20:25] We all need to have these case based scenarios or, the incorporation of those different strategies based on again, what the goal is and what the. Save changes. You don't wanna make someone practice something if they don't have the foundational knowledge. But really relying on the learning science is what we should be doing.

[00:20:43] And in the same breath, I think what's important that isn't lost that some people rely on. maybe start the conversation by talking about learning styles is accessibility, inclusivity, really ensuring universal design [00:21:00] principles that we are differentiating learning when needed, that we are learners where they are in terms of their stages of change.

[00:21:07] But that's different than the style, right? Or preferred way of

[00:21:11] Alex

And I have links that I can make sure to include in the show notes for Universal Design and some of the things that you just mentioned there.

[00:21:19] So for anyone who's looking to build their capacity in this field in learning design, where, where should they start? Do you have a good resource, a go-to resource that you like to direct people to?

[00:21:33] Sarah Atwood

In terms of framework, I have been encouraging folks to learn more about behavior change if they're not already well versed. So things like stages of change or theory of planned behavior.

[00:21:47] Alex: Mm-hmm.

[00:21:47] Sarah Atwood: To learn more about behavior change frameworks. I think that's a good place to start, I think for folks who don't have a background in instructional design, [00:22:00] understanding the ADDIE framework, I know we talked a little bit about how some folks follow PDSA, PDSA is great for lots of different. Process improvement or outcomes testing. I love Addie as a really systematic structured approach that can be applied iteratively. So I think a criticism of Addie historically is like, oh, it's not agile, it's not iterative. It should be applied iteratively. And so yeah, I think that classic design process is also a good place to start. There's a great little book by Clark Quinn called The Learning Science for Instructional Designers. It's like a hundred pages. It's a primer on learning science and includes, references in the back. But I think that's also a nice practical place to start.

[00:22:47] A lot of people in our field who are working out loud, and I really love to follow those folks. Connie Malamed, who runs the e-learning coach site, she is really practical. [00:23:00] Interviews for articles with references.

[00:23:02] Staying on top of the research in general just as any other field is super valuable.

[00:23:09] One thing that I would really encourage folks to consider in the design and development of activities is confirming whether the strategies they use, whether they know they're evidence-based. So like, why are you including this on a slide, or why are you approaching a scenario this way or, what is the rationale behind those design decisions?

[00:23:35] I think that just stopping and thinking about that's been a good practice for me in designing education is this really grounded in evidence that's gonna help the learning stick.

[00:23:45] Here are my three big takeaways from this conversation with Sarah Atwood.

[00:23:50] First, effective CME design isn't just about delivering content. it's about applying learning science, so knowledge actually sticks. [00:24:00] Perhaps that much is obvious, but perhaps less obvious is that second behavior change requires much more than awareness. Frameworks like the stages of change can help us design education that meets clinicians where they are.

[00:24:16] For examples of how this works in practice, checkout episode 56 of Write Medicine with Sara Johnson of Pro Change. And Third Patient Co-Creation makes education more human-centered, aligning clinician and patient learning for better care. And here's one action step you can take right away.

[00:24:37] The next time you're developing continuing education content, just pause and ask yourself, am I designing this for knowledge transfer or for actual practice change? That simple shift in perspective can potentially transform your work. On the next episode of Write Medicine, we'll hear from psychotherapist and freelance business [00:25:00] coach Hope Lafferty, who joins me for a candid conversation on professional identity trauma and building resilience as CME professionals.

[00:25:09] In the meantime, subscribe to Write Medicine so you don't miss an episode. Go to www.writemedicine.com and click the follow tab to subscribe on your favorite listening platform. And if you want deeper resources, tools, and strategies,

[00:25:26] get on my email newsletter list. alexhowson.kit.com/newsletter. Yes, I know it's a lot to remember and that's why you'll also find a link in the show notes.

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