Increasing awareness of AL and it’s lack of use as well as extending the use of this AL survey instrument and methodology to other areas of medical education were important goals in publication of this study. However, the primary goal of this survey was to extend the results of the 2018 Harrison survey and address unanswered questions about the knowledge, usage, attitudes, and barriers to usage of AL strategies in academic CME units in U.S. and Canada. The results suggest that many CME unit leaders are well-trained and have education in AL as well as positive attitudes towards the use of AL methods, but the change from the lecture format to implementation of AL methods has been minimal. While the mission of the Accreditation Council for Continuing Medical Education (ACCME) is to “assume and advance quality learning for healthcare professionals that drives improvements in patient care” , the translation of knowledge into practice that improves patient outcome is complex . Although much has been written about the quality of health care delivered in the U.S. [17, 18], the challenge for CME is to deliver impactful medical knowledge in a way that providers are able to retain and engage with the delivered knowledge in order to stay current and improve patient care.
In general, faculty members have not kept pace with pedagogical advancements and knowledge of medical education delivery methods . Little is known about the actual training and knowledge of CME unit leaders in AL methods. In our study, we found that many of the CME unit leaders have both formal and informal training that included information about AL. More than half of the respondents consider themselves knowledgeable about AL methods. Learners in these institutions may have an edge since engagement and translation of the knowledge facilitates changes in practice and improved patient outcomes .
While the practice of medicine has changed dramatically during the last half century and knowledge and information have proliferated over the last several decades , medical classroom teaching has not changed substantially and is still driven by the lecture format . Our study confirms that change in teaching methods comes slowly. Despite the fact that most of the respondents in our survey described themselves as knowledgeable about AL methods, 80% reported that AL is used in less than half of the CME activities at their institutions. When AL strategies were used, audience response polling, simulation, and group discussions were the most common. We asked survey respondents about the source of their responses to determine the accuracy of their reporting. They indicated that their answers were mostly based on factual CME unit data and frequent attendance at lectures, courses, or conferences at their institutions, validating the accuracy of our study findings. Taken together, the positive correlation of advanced training and self-perceived knowledge with use of AL suggest that many CME unit leaders are trained to use and facilitate these teaching methods in their institutions.
There are many AL strategies for instructors to consider when they design courses, but negative attitudes and pedagogical barriers must be overcome . When exploring these potential attitudes of CME unit leaders, our survey demonstrates that survey participants recognize to a large degree the importance of learner engagement to increase knowledge and recall. They also agree that instructors who use AL are more concerned with facilitating reflection and working cooperatively with the learner. As a result, instead of merely conveying facts to the learner, knowledge can be applied in practice. While more than 60% of survey participants indicate that lectures are not difficult to adapt to AL methods, instructors at their institutions, nevertheless, do not incorporate AL methods to a large degree into their CME activities. Our study confirms that the benefits of AL are recognized but practical implementation still lags behind in many institutions.
While respondents have knowledge, positive attitudes, and perceptions about AL, we still needed to explore barriers to AL and describe resources needed to overcome these barriers to better understand the challenges of CME unit leaders in their institutions. In STEM disciplines, barriers to use of AL methods are described as “complex”  and include the triad of lack of time, training, and incentives to implement educational change. In medical education, however, barriers to use of AL have not previously been described. In our study, we found similar barriers identified by the STEM disciplines and additional resources are needed for preparation, planning, and faculty development. Other barriers include a lack of administrative support and change-averse cultures at institutions. Similar to the STEM disciplines, assistance from educational designers, institutional recognition, as well as additional training and faculty development in AL was found to be useful for increasing the use of AL in CME.
The strengths of this study are the methods used to develop the survey. Questions used to develop the construct, AL, were developed through an in-depth literature review of AL. Survey development was also guideded by Messick’s five sources of validity evidence . Although content and response process validity are strong because of use of extensive pretesting and cognitive interviewing of the study population prior to dissemination, the lack of established criterion validity is a limitation of the study and will be an important next step in this area of research. Buy-in from SACME also facilitated survey distribution to ensure that all members of the society had an opportunity to respond to the survey. Following survey distribution and data collection, we evaluated reliability of the survey instrument. Although one of our subconstructs, ‘Active learning strategies currently used in CME units’ had lower internal consistency reliability related to the yes/no question type and distribution of the data, the Likert scale survey questions demonstrated high internal consistency reliability as confirmed by Cronbach’s alpha.
Limitations of the study include low response rates as observed with on-line surveys. Reasons for this include potential incorrect email addresses, survey fatigue of the study population, and membership changes within SACME, whose membership is dynamic. The varying number of SACME listserv members, directly impacts the denominator. Although voluntary responses improve the quality of the responses, non-response bias must also be considered. Since it could be inferred that individuals more interested in AL were more likely to complete the survey, we attempted to limit non-response by frequent reminders. Since non-response bias also increases the likelihood of differences in the group of respondents compared to non-respondents, we followed up with telephone surveys of 10 randomly selected nonrespondents to validate the results of selected questions. Results of these telephone surveys were similar to online survey results, indicating a small effect of non-response bias on our results. Although some institutions may have been represented by several respondents, the anonymous nature of the survey and heterogeneity in responses limits this concern. The non-validated nature of self-reported items such as training, knowledge, and use of AL represent other recognized limitations. Finally, the use of AL cannot make up for poor event content, even if AL is used as the teaching method.
This study is the first to expand one conclusion of the 2018 Harrison survey by describing the knowledge, usage, attitudes, and barriers to implementation of AL strategies in academic CME units in the U.S. and Canada. Our results suggest that increased levels of self-perceived knowledge but not advanced training are associated with increased use of AL. Despite CME unit leaders’ training, education, and positive attitude toward AL, the use of AL is infrequent in many CME units, often as a result of limited resources including faculty development and institutional recognition for AL teaching. Future directions include extending the survey and its methodology to other areas of medical education such as undergraduate and graduate medical education, incorporating qualitative data (e.g., in-depth narrative data) to gain better depth of understanding of the AL construct, as well as follow-up with similar surveys done in tandem with other aspects of the Harrison survey to trend the data. We would welcome collaboration by the AAMC and SACME to create awareness of AL and the considerations of its use and implrmentation.