Jack Dolcourt, MD, MEd

1
Commitment to Change Research and Theory
Informing Practice

• Jack Dolcourt, MD, MEd
• University of Utah School of Medicine
• Primary Childrens Medical Center
• Salt Lake City, Utah
• Contact information jack.dolcourt_at_hsc.utah.edu

2
Disclosure

• The content of this presentation does not, will
  not and cannot relate to any product of a
  commercial interest therefore, I have no
  relationships to report.

3
My Aha Moment

• Commitment to change is like Radio-Immuno Assay

Thyroid Foundation of Canada
Egan KL. Commitment for change-a Radioimmunoassay
for Continuing Medical Education. In Davidoff F,
ed. Who has seen a blood sugar? reflections on
medical education. Philadelphia American College
of Physicians, 199629-33.
4
Commitment to Change

• Easy, explicit/observable, change in practice
• Avoids cueing because it is open ended
• Compare learner responses with faculty goals
• CTC is a force to change/reinforcement
• Direct measure of CMEs effectiveness survey for
  accomplishment

Egan KL. Commitment for change. In Davidoff F,
ed. Who has seen a blood sugar? reflections on
medical education. Philadelphia American College
of physicians, 199629-33.
5
CTC Make Thoughts Visible

• I can now get inside their head.

6
My Questions

• How can I do a CTC for myself?
• Is self-reporting valid?
• Are CTCs effective in facilitating behavioral
  change? Are they predictive of actual behavioral
  changes?
• What is the theoretical basis for CTCs?

7
Malcolm Knowles
Assumption Adult learners orientation to
education

• Education increased competence to achieve full
  potential
• Want to apply knowledge
• Learning experienced around competency-development
  
• People are performance-centered

Knowles MS, Holton III EF, and Swanson RA. The
Adult Learner (5th ed). Houston Gulf Publishing
Co, 1998.
8
Question 1 How can I do a CTC?

• Purkis (1982) instrument for evaluating CME
  courses
• n39 physicians at a pain symposium
• 72 made 1-3 commitments (total 67 CTC)
• 93 had made at least 1 change at 2 months
• 63 of CTCs implemented at 2 months
• 27 not implemented b/o lack of suitable cases
• Indirect evidence for changes in behavior
• Reinforcement of learning
• Identify teaching points that had greatest impact

Purkis IE. Commitment for change an instrument
for evaluating CME courses. J Med Educ 1982
57(1)61-63.
9
Question 2 Is Self-Reporting Valid?

• Curry L Purkis IE (1986) used carbon paper
  prescription pads (n61)
• Behaviorist model (S?R)
• Self reports sufficiently valid actual
  behavioral change, when there was an intention to
  change at -6 vs. 16 wks ranged from plt0.001
  p0.04
• Many CTCs unrelated to instructors essential
  points, combination of teaching points or were
  tangential, minor or not taught at all.
• match between course content reported change
  will be discouragingly small
• Self-reporting is valid but why discouragingly
  small?

Curry L, Purkis IE. Validity of self-reports of
behavior changes by participants after a CME
course. J Med Educ 1986 61(7)579-584.
10
Educational models

• Constructivist model
• People construct their own understanding and
  knowledge of the world through experiencing
  things and reflecting on those experiences.

Tyler model
Step 1 Whats the Problem/Need?
Step 2 Define the goals or Objectives
Step 4 Evaluation
Learning Cycle
Step 3 Teaching
Tyler RW. Basic principles of curriculum and
instruction. Chicago University of Chicago,
1949.
11
Question 2 (contd) Is Self-Reporting Valid?

• Wakefield J et al (2003)
• Prescription records -1 yr to 6 months
• n207 physicians in peer learning
• 91 planned to make at least 1 change
• Total of 209 committed-to changes
• 71 Rx CTCs accomplished

Wakefield J et al. Commitment to change
statements can predict actual change in practice.
J Contin Educ Health Prof 2003 2389-93.
12
Question 3 Do CTCs Facilitate Behavioral Change?

• Pereles L, Lockyer J. et al (1997)
• N26
• CTC group made more changes types of changes
  were more difficult p0.07

Pereles L, Lockyer J et al. Effectiveness of
commitment contracts in facilitating change in
continuing medical education intervention. J
Contin Educ Health Prof 1997 1727-31.
13
CTCs to Learn More About

• Educational model Tyler (teacher centered) vs.
  Constructivist (learner centered)
• Egan This fundamental question about CME has
  never been answered
• Purkis evaluation for teaching points that had
  the greatest impact

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CTC Form
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Results-part 1

• 61 attendees, multidisciplinary, 70 participated
  
• 1 month n33 completers with 119 CTCs
• 54 of the CTCs were self-reported to have been
  implemented by 1 month
• 88 of unimplemented CTC still in process
• No relationship number of CTCs and audience
  perception of attaining predetermined objectives

Dolcourt JL. Commitment to change a strategy for
promoting educational effectiveness. J Cont Ed
Health Prof 2000 20156-163.
16
Results-part 2 Unanticipated Learning

• Predicates CTCs compared to predetermined
  instructional objectives
• 68 CTC predicates matched objectives
• 32 CTC unmatched (unanticipated learning)
• No CTCs for 34 objectives

CTC
Objectives
Unanticipated learning
Dolcourt JL, Zuckerman G. Unanticipated learning
outcomes associated with commitment to change in
continuing medical education. J Cont Ed Health
Prof 2003 23173-181.
17
Take Home Messages

• CTCs better and fuller evaluation tool than
  meeting objectives
• Instructional objectives dont account for all
  learning and behavioral changes
• Learners interpret adapt new knowledge with
  consideration for previous life experiences

18
CTC for Understanding Use of Knowledge and Skills

• Degree implemented (full, part, none)
• n352 physicians at 21 centers - 1,635 CTCs
• 6 mos 57 provided F/U data
• 55 CTCs implemented of these, 67 fully
  implemented 48 of fully implemented CTC in 2
  areas-58 course time allocation
• Is follow-up part of the reflection exercise or
  an intervention in its own right?

Lockyer JM, Fidler H et al. Commitment to change
statements a way of understanding how
participants use information and skills taught in
an educational session. J Cont Ed Health Prof
2001 2182-89.
19
Theoretical Foundations

• Unclear conceptual psychological framework
  underlying CTCs
• What does commitment mean?
• Binding an individual to a behavioral act?
• Attitude and belief?
• More than an evaluation tool
• Strategy for ? likelihood of follow-through

Mazmanian PE et al. Commitment to change
ideational roots, empirical evidence, and ethical
implications. J Cont Ed Health Prof 1997
17133-140. Mazmanian PE, Mazmanian PM.
Commitment to Change theoretical foundations,
methods, and outcomes. J Cont Ed Health Prof
1999 19200-207. Overton GK, MacVicar R.
Requesting a commitment to change conditions
that produce behavioral or attitudinal
commitment. J Cont Ed Health Prof 2008
28(2)60-66.
20
What this Research Tells Us

• Lectures do affect change
• CTC more than eval tool
• CTC may be force for change/reinforcement
• Self-reporting is valid
• Easy, explicit/observable, change in practice

• CTCs better and fuller evaluation tool than
  meeting objectives-categorization
• By topic-what worked
• Unintended learning
• Time allocation
• Direct measure of CMEs effectiveness survey for
  accomplishment

21
Score Card

• Canada Scotland USA

22
Bibliography

• Curry L, Purkis IE. Validity of self-reports of
  behavior changes by participants after a CME
  course. J Med Educ 1986 61(7)579-584.
• Dolcourt JL. Commitment to change a strategy for
  promoting educational effectiveness. J Cont Ed
  Health Prof 2000 20156-163.
• Dolcourt JL, Zuckerman G. Unanticipated learning
  outcomes associated with commitment to change in
  continuing medical education. J Cont Ed Health
  Prof 2003 23173-181.
• Egan KL. Commitment for change-a Radioimmunoassay
  for Continuing Medical Education. In Davidoff F,
  ed. Who has seen a blood sugar? reflections on
  medical education. Philadelphia American College
  of Physicians, 199629-33.
• Knowles MS, Holton III EF, and Swanson RA. The
  Adult Learner (5th ed). Houston Gulf Publishing
  Co, 1998.
• Lockyer JM, Fidler H et al. Commitment to change
  statements a way of understanding how
  participants use information and skills taught in
  an educational session. J Cont Ed Health Prof
  2001 2182-89.
• Mazmanian PE et al. Commitment to change
  ideational roots, empirical evidence, and ethical
  implications. J Cont Ed Health Prof 1997
  17133-140.
• Mazmanian PE, Mazmanian PM. Commitment to Change
  theoretical foundations, methods, and outcomes. J
  Cont Ed Health Prof 1999 19200-207.
• Overton GK, MacVicar R. Requesting a commitment
  to change conditions that produce behavioral or
  attitudinal commitment. J Cont Ed Health Prof
  2008 28(2)60-66.
• Pereles L, Lockyer J et al. Effectiveness of
  commitment contracts in facilitating change in
  continuing medical education intervention. J
  Contin Educ Health Prof 1997 1727-31.
• Purkis IE. Commitment for change an instrument
  for evaluating CME courses. J Med Educ 1982
  57(1)61-63.
• Tyler RW. Basic principles of curriculum and
  instruction. Chicago University of Chicago,
  1949.
• Wakefield J et al. Commitment to change
  statements can predict actual change in practice.
  J Contin Educ Health Prof 2003 2389-93.