Write Medicine

Scaffolding Behavioral Change

April 04, 2022 Alexandra Howson PhD Season 3 Episode 23
Write Medicine
Scaffolding Behavioral Change
Show Notes Transcript Chapter Markers

Brian McGowan PhD, FACEP planned to be the team orthopedic surgeon for Notre Dame football. After a month of working in an orthopedic rehab hospital when he was in college, he realized that he didn't know what he wanted to be when he grew up, but it wasn't going to be a physician. 

Lucky then for us. 

Brian has worked in academic, industry, and is co-founder of ArcheMedX. But the places he's been do not mark who Brian is. It's his passion for behavioral science, learning science, and research into medical education methodology that make him inimitable in the field of continuing education for health professionals.

Join us for a conversation about what continuing education practitioners can do to help learners think more efficiently and effectively. Points of interest include: 

✔️ Which root skills are most important for CME storytellers 
✔️ What the Ebbinghaus experiment is in learning science 
✔️ How physical environments affect learning 
✔️ Brian’s love for the three-slide-per-page print option for PowerPoints 


Connect with Brian
email: brian@archemedx.com

Connect with Alex
email: alex@alexhowson.com  

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 Hello, and welcome to Write Medicine. I'm your host, Alex Howson. And today we're talking with Brian McGowan. Welcome, Brian.

Brian McGowan  00:20
Thank you for having me.

Alexandra Howson  00:22
It's good to have some time to have a conversation with you. Because I think I've only, we've only ever sort of seen each other in passing. So as you know, you know, I like to start the conversation by just getting to know you a little bit better in terms of how you found your way into continuing healthcare education. So if you could share a little bit about your background and how you kind of ended up in this space?

Brian McGowan  00:51
Sure, thanks. And yes, we haven't spent much time together, but I feel like I know you having listened to your very thoughtful interviews with previous guests. So. I am, I went to medical school. I went to medical school because from the time I was seven years old, I knew that I was going to be a physician. And more importantly, I knew I was going to be the team orthopedic surgeon for Notre Dame football, either that or a priest because that's what people in my family did. And I figured if I went to Notre Dame, it was close enough that my parents and grandparents would still get the points that they deserved. So I spent from the time I was seven until the time I was 18, preparing to be clinician, a physician and an orthopedic surgeon. I went to college, played college football, and in the offseason, I worked at an orthopedic rehab hospital. And after about a month of working in the orthopedic rehab hospital, I realized that I didn't know what I wanted to be anymore, but it wasn't going to be a physician. I just kind of you know, maybe in those first couple sentences, you realize that an orthopedic surgeon and a football player, there's like kind of stereotype in between those two different positions. And at 18 years old, I was that person. I was an absolute lunkhead and, and I, at the age of 18, working in this orthopedic rehab hospital, I realized the difference between injury and illness. And I had never confronted illness before in my life. I never thought about illness. And when I realized that to do what I’d always thought I wanted to do, I'd spend about 15 to 20 years through medical school and fellowships, internships, and even young practice. I'd be, I'd have to work through the, the illness side of medicine. Concurrent with that medicine was rapidly changing. This was 1991, ‘92, ’93, and EMRs were coming about and I knew people who were physicians and they were starting to see the horizon of being stuck behind the computer screen instead of looking in the eyes of the patient. Just that concurrence I remember clear as day I was working with Doris Schwartz, she was 85 years old, she was coming off a hip replacement, and she did not want to get better. And I couldn't imagine not wanting to get back on the field, so to speak. And to her, this was just another step until she was no longer with us. And I just was not mature enough at the time to cope with that. And so I ended up going to medical school, I was so far down the path. But shortly after getting, going to Temple School of Medicine, I switched to a research track instead of the clinical track. So after the second year, and all my classmates went into the rotations, I was in the laboratory and actually even as early as a month before my first medical school class, I was already working on the research side, I had a doctoral advisor who was the head of heart transplant, at Temple. And so that got me on the transplant program. And I spent four and a half years at Temple in and around classes working in a transplant lab and we were very early stages of left ventricular assist device trying to heal, heal the heart and bridge the heart instead of just going right the transplant and so that that allowed me, to I think we were on, gosh, the number escapes me now I'm going to say 274 heart transplants in four and a half years, many of which I had to get into a chopper and fly and do an explant. So someone who was donating all their organs, if there was any sign that the heart wasn't healthy enough to be transplanted, maybe they hit a steering wheel or maybe they as they flipped over their motorcycle, they, they did a little bit of damage. There was a little bit of ultrasounds, irregularities that they would take the heart or they take the eyes, they take the kidneys they take the lungs everything that could save other lives and help other people. And then I would walk in and there's this cadaver, left over and the heart's been cooled and stopped. It would go in a bucket, come back with me. And we had a group of about 14 to 20 scientists that would all arrive at the laboratory, often at 2 or 3 o'clock in the morning, and start doing whatever experiments we can get, because we didn't get many of these things. Kind of came and went. So that was, that was the journey and that got me all the way through medical school, graduated, did a couple postdocs, translational medicine, but spent most of my time in an OR research laboratory, working in different heart failure models or myocardial infarction models. And after two or three years of internship, I had a couple faculty offers and I none of them really struck me as all that interesting to me as a 26- or 27-year-old So, University of Rochester, University of South, Sioux Falls in South Dakota, University of Wyoming, distant places that the city boy didn't really see as being all that pleasurable.

Alexandra Howson  06:03
Well, Mayo is at Rochester, right?

Brian McGowan  06:06
Yes, yes. It’s still really cold. So I, I had, I had an absolute great opportunity because my doctoral advisors, because I was part of this heart transplant program. I knew 10 or 12 of the most renowned cardiologists in the country. AstraZeneca had just made a $14 million grant. One-time, $14 million grant for independent medical education. Yep. This is, they were about to launch the fifth lipid lowering drug, the fifth statin on the market, Crestor, at the time, or just launched. And through a contact, the faculty of the program, said, well, we need somebody who can be the medical director behind the scenes. And, and so I was offered, straight out of my last fellowship, I was offered the role at a medical education company serving as a medical director overseeing one of these large projects or being a part of one of these large projects. And it's interesting, because if you look through it, some of the people that I originally worked with on the first job are still at it. Beth Berlinger at Pfizer was one of the first people. Jen Smith, who ended up running Wyeth med wd group, and brought me in many, many years later. Gosh, Celeste Kolonko, I think there's probably about six or seven of the folks that all connect back to 2003, 2004. And so that was my, my first pass to like, I didn't really have to make it up the ladder much in medical education, because I was kind of brought in by some of the cardiologists. And so it was, it was interesting. Someone pushed the fast forward button in my career, and it kind of helped. So that got me into it. I spent two or three years doing that then went to work for a supporter, and that was Cephalon at the time with Karen Roy, Jackie Brooks, oh, Karen, our friend Irish Karen. And did that for two years, went back to the agency side for another two years. Then Jen Smith brought me back in and I ran all of Wyeth's medical education for about a year and a half until Pfizer consumed us. Spent another year and a half now, now with Maureen Doyle-Scharff and Bob Kristofko. And so we're moving into 2008, 2009. And I got to oversee all of oncology education for Pfizer for a year before I left. So having gone back and forth on both sides, always on the teaching, data science, learning science side of this community that we're all part; of working with medical writers, running the editorial content staff for the various organizations that was a part of and, you know, just recognizing that there were very few people that had my path. I wouldn't say my path was like most you know, a lot of people say they fell into it, no one expected to be it. I didn't expect to be in it. But to me, it was just a scientific research pursuit, just like I was doing in the research lab, but now, I was studying how people learned and how we could help them learn more efficiently. And so I've always had that think like a scientist kind of research background, which was really unique, still is pretty unique to this day.

Alexandra Howson  09:43
So let's talk about that a little bit. I mean, there's a lot in there and it's interesting that the point of connection for me is I was an OR trauma nurse for many years. So the, the things that you're saying about orthopedic surgeons are you know completely recognizable. Who decides that they're going to be an orthopedic surgeon? I think that's another conversation to have, because it definitely takes a particular sensibility and orientation to the world. But I wouldn't,

Brian McGowan  10:15
That is the kindest way I think it’s ever been described.

Alexandra Howson  10:18
Yes, I'm, I'm nothing, if not, what's the word? I don't have any words this morning, I'll come back to that. Discrete is not the word I'm looking for. But you're talking about, you know, having the work that you're doing, or that you, you began to do in continuing healthcare education as having a kind of family resemblance to the work that you were doing as, as a research scientist, can you talk a little bit about how you began to kind of navigate your way around a quite distinct world of education, in continuing medical education, as it most definitely was at that time, that's before, you know, continuing education really began to sort of widen out to include other health professionals in a very kind of explicit way. So when you looked at or when you look back at what you saw in that world, when you first entered it, what did you see that was significant, interesting, and that needed to be changed or improved?

Brian McGowan  11:30
Yeah, there's, I remember, early on when, even when the first roll with the large, dyslipidemia program, and over a year and a half or two years, we had probably hired five or six different medical directors, medical writers to come in. And almost all of them were writers, were English majors. Occasionally, there were some MDs or pharmacists who were just leaving clinical practice. And what I found really early on is that the telling the story, and the asking the questions, are a competency set that not all MDs or clinicians had. Like some people could tell good stories, some people could write good prose. Other people could ask questions, and there weren't too many people that did both of them. And I found myself I think I was on a run at one point where I’d hired 10 to 12 PhDs. Because I found like, it was easier — I found like, it was easier. That was a great sentence, I found that it was easier for people who could ask questions, who could understand the scientific method, I found it was easier for them, for me to train them to tell stories, and to eventually understand the learning science than it was for somebody who had some learning science background or was a writer. And so those kind of pattern recognition exercises that I went through pretty early in my career, that, that recognition of what the strengths and weaknesses were of somebody who was growing in the profession. But all that’s to say, I probably wouldn't have identified any of that if Jen Smith didn't hire me and Mark Samuels didn't train me as like a first-time business person trying to understand what the business of all of this was at that point. But your point about it being a very different world. Clear as day I remember about five or six of the leadership team being brought in on a Friday afternoon, in a Saturday morning. This is just when the concrete wall between independent medical education and promotional medical education was being requested and demanded in some cases. And the company we were working with did a little bit of everything. And like many did at the time. And so we got called in and we basically put names on a dry erase board of every employee in the company and we had a draft, we had to decide by Monday morning or we were gonna lose seven figures worth of business in different, from different organizations, we had to decide how we're going to find the firewall. And I use the word, this concrete wall because by Monday morning, we had concrete walls built in our office. Not only did we draft all the staff, but we had a debate for half an hour, 45 minutes about whether the kitchen should be entered from the promotional side of the office space, or where the kitchen should be entered from the independent medical education side. And project managers who had been managing projects across both sides. They would get split. It's like I'll give you an Amy and a Matt. But we really need Tiffany on this project. I mean, just unexpected, unusual times. None of it had to do with the learning science. It all just had to do with righting the ship really, trying to you know create the, the foundation that we needed so that independent medical education could do what it really is intended to do and not really be, be wagged by the tail

Alexandra Howson  15:03
So let's talk about, yeah, let's talk about the learning science because you've obviously mentioned that a few times, and my guess is that no one was talking about learning science back then.

Brian McGowan  15:13
I guess you can't see my head nodding on a podcast. But no, no, no one was talking about it.

Alexandra Howson  15:17
So tell me about your, your, the opening up of learning science as an intellectual field for you and how you began to see the alignment between learning science in a research context and learning science in an education context.

Brian McGowan  15:42
So there was a little bit more background to share. And that was even when I was at Temple, Medical University of South Carolina, and eventually Jefferson for my postdocs. I had teaching responsibility the entire time. So I started proctoring and teaching anatomy and physiology lab. And then my field of doctoral research was cardiovascular physiology. So basically, root physiology was my foundational learning. And so I taught the physiology course for — proctored some of the activities for the medical students, I taught the pharmacy and dental programs’ physiology courses, and was eventually after like, my second or third year, I was hired at a small liberal arts college that had a genetic counseling program called Arcadia University just outside of Philadelphia. And so I was the course director for that. And whether it's a strength or a weakness, the idea of teaching and trying to impact change on people and not measure it and try to understand of the 16 or 18 people in my class for the genetics counseling program, or the 200 people in my class for some of the physiology courses, why it was working, for some people not working for another person, the idea of going through the work and not trying to do it as well as, as good as possible just is foreign to me. So the idea of having to measure quickly came forward. And, and then that, that, so that evolved and emerged for seven or eight years. And then if you can picture this: you're a commercial supporter. And on your desk is 30 different proposals, each making claims about being the best, about being award winning, about demonstrating this change and that change. And as you look through it, you realize that there's, there's no way to compare this person saying they’re the best versus that person saying that they’re the best and the percentage changes that people were claiming it made me ask quickly, like, what the methodologies were that they were using, whether there was any statistical validity to any of it that certainly those questions were raised pretty quickly. Nobody knew the answers. There, you know, so. So this is pre Moore's framework, as we know it. Right? It's certainly done, had started on at a decade prior. Right. So there was this, these emerging frameworks, we obviously had Kirkpatrick at that time, and we had Miller and we had some others, but none of them were explicit enough and how to measure it was basically these are the constructs in which you should be measuring. And it gave you a little bit of a framework to work within. But there was very little of that, certainly, very little of that in medical education, the commercial support side of all this. It was existing and emerging very — there was some robust work being done in academic medical centers and graduate medical education and a little bit in postgraduate medical education, much higher stakes learning experiences, and much more expensive learning experiences. And so people really wanted to know what was changing. But in medical education, in continuing medical education at the time, there was very little, very little. So seeing, seeing what was missing and having it so blatantly in front of you, either of these learners, a third of them aren't evolving as quickly as you'd expect, you start to understand what zones of proximal development are and what scaffolding is, and, and what episodic, and you know, you you run face first into Ebbinghaus very quickly. And so then you start asking even more questions. So

Alexandra Howson  19:39
Explain Ebbinghaus for me.

Brian McGowan  19:43
1883, Ebbinghaus was a psychologist, I believe, and he and his family did a series of experiments where they were trying to see how long they could remember things. The classic Ebbinghaus experiment is that he would, uh created a list of three letter, non-verbalized nonsense syllables, K T X. And he would memorize them. And then he’d test himself. And if he got them, right, good, he'd save a day or two or a couple more hours, he'd measure himself again, he'd measure himself again, trying not to re-study just trying to see what he remembered. And when he published his work, it changed the world — should have. Because he realized that the cliff at which people forget things is so much more severe than even in 2021, we believe it is. Like it is the matter of hours, and days, not the matter of months, and years. And yet, and so that research, similar research has been reproduced in non-nonsense syllables and much more real-world scenarios, and it plays out pretty consistently. And so when you see people forgetting things, when you see people not remembering, not learning, not evolving, not being able to simulate not being able to creatively think about the root information that they learned? As an educator, it’s on you to figure it out. At least that's the way I always thought about it. Maybe you have to. We've met educators who will tell you that it's not their job. For the students to learn, it's their just their job to teach, which is one of the weirdest things I've ever heard in my professional career. But I haven't just heard it once. I've heard it many, many times. Up until two or three years ago. I remember a faculty member who I thought I had respect for tell me it wasn't his job to help them learn. It was simply his job to teach.

Alexandra Howson  21:42
Separation of teaching and learning.

Brian McGowan  21:47
Yeah, accountability and responsibility, it gets one of these different strokes moments, I remember saying to him, What are you talking about? Well, it's very strange.

Alexandra Howson  21:55
Let's talk about — So thank you for sharing that. I wasn't actually familiar with that. I'm not familiar with that experiment at all. But it does take us into one of your key insights around learning as a behavior and the role of memory and recall in, in learning. So. You say, learning as a behavior, what do you mean by this? And what led you to that insight?

Brian McGowan  22:23
So somewhere about 2007, 2008, I stumbled on a book called Stumbling Into Happiness by Dan Gilbert. Looking at my bookshelf, and Dan's book is — Harvard psychologist, brilliant. His concept is one of the first books I'd ever stumbled across that talked about how we think, and how little we understand about how we think. And his point is happiness versus anxiety versus stress. A lot of that has to do with the disconnect between how we think we think and just clairvoyance of how we think we think. Hindsight is 2020, these types of things, versus the realities of how we think. And it just fascinated me like it was, I’ll never forget the initial reading, or the next four or five readings of the book. And from that, I gained a passion for thinking about thinking. And so that led me to find the work of Kahneman and Tversky, dating all the way back to the late 60s and early 70s. And Dan Ariely was just beginning to come out with his irrationality research. And fast forward 15, almost 15 years later, and now we have like the Adam Grants and the Katy Milkmans of the world talking about how we should think and how we should decide. And this bookshelf next to me has probably close to 80 books. And you might be surprised to find out that less than 20 of them are learning science books, they're almost all behavioral psychology, cognitive psychology, and behavioral economics. And so that that idea of like how we think versus how we think we think, is just so fascinating to me. And so, again, maybe it's just a pattern, I started to wonder about how we learn versus how we think we learn. And so about 2009, 2010, I started a grassroots kind of mini research project and ended up I interviewed originally 300 before the conclusions were drawn, and now I've probably done it over 1000 times where I'd ask a clinician how they learn. And so it was kind of a structured interview. So when you're sitting in a lecture hall or your participating in online education, you're in a formal learning environment. And the facilitator or the textbook or the video, something strikes you, you have that initial moment where your wheels start turning and it feels like you're learning. It's the feeling that people were describing to me. What do you do in that moment? And people would say, look like, if I was reading a book, maybe I'd highlight something or I dog ear, the pages or maybe I'd enter something in my Blackberry at the time. Maybe if I'm participating in a live symposium, maybe I write something down on the cocktail napkins, or there's little seven by eight pieces of paper that the hotels give us. And then I'd ask so now you have this piece of information, you wrote something? Can you tell me a little bit more about what you wrote? Like, were you transcribing it? Were you just verbatim writing it back down again? So I started to try to understand the note taking behaviors and some of the intentions behind them. And so now, at the end of this activity, how many of these notes do you have? Well, I may have five, I may have 20. I may just try to write down one thing. Again, 300 interviews, a lot of heterogeneity there. What do you do with those notes afterwards? Oh, well, if I'm in a hotel room, or a conference room, sometimes I just leave them on the table and like, the fact that I wrote them down, maybe helps me. I had one clinician tell me that they had two big meetings they went to every year. And they brought the same exact notebook to the spring meeting, and a second same exact notebook every year to their fall meeting. And they about a week before the spring meeting, they would open up — now this is one of the best behavioral structures I've ever heard of a learner. And at the end of it, you're going to realize how disappointing it is. But this is a clinician learner, who for 20 years had this notebook, and a week before their spring meeting, they would open up the notebook, and they would have pangs of regret. Look at all this stuff I wrote down last year, I didn't do anything with it. I came back, the book sat on my desk for a week, I intended to look at it again, I intended to do something else with my notes. And then my desk would get cluttered with journals. And I'd move it over to the side of my desk, and then that part of my desk will get cluttered with journals. And about a month after I returned from my spring meeting, it will go right back up on the bookshelf. Until the fall meeting, when I grab the other notebook, and I go through the same thing over and over again. So here's this clinician, and she had all of her notes for 20 years. And those notes were only in her consciousness for approximately a week and a half span in and around their annual meeting. And she always had great intention, she was going to lose weight in January. But somehow she didn't lose weight, she was going to start exercise, it was, kind of see the pattern? She was going to use her notes more effectively, she built the structure to use her notes more effectively. But she's just not reflective in her thought next Tuesday when she has to rush to her daughter's soccer game. And she still has three charts that she has to review. Then life takes over and willpower is not enough. And those exact same lessons have been learned in behavioral economics and in cognitive psychology over the last 15 or 20 years. What do we need to do for people to help them think more efficiently, to help them make better decisions when they can't always help themselves? Well, to me, that's an instructional design model. So now as a, as an educator, I know that for my learners to be effective; for them to be their best learners that best version of themselves; then I need to create a learning experience that understands the behavioral limitations, the attention limitations. And so if you think about a lecture, you may have participated in a college when a faculty member tapped her knuckles on the podium and said, This is going to be on the test. Well, damn well sure you just switched to reflective thinking mode right there. Now, that's a pretty stark and very frank type of nudge. But that was a behavioral nudge. And so I started to think through all this, we have the problem of people not necessarily knowing when to take notes or not understanding what the important things in content are, or not, not being able to relate what's important to them to a series of behaviors that will ensure that you've actually learned and you've surpassed Ebbinghaus’ forgetting curve, and it's a month later and there is some value to it. And I started to do the math like for one ASCO meeting. If there's 30000 people there, now up to 40000 people, and of those people about 20, 25000 Are there to learn, they’re clinicians that in some way are there for some continuing education experience. And 90% of them have never actually been trained and how to affectively learn. Which is what my research suggested 1 in 10 of the people I interviewed said they had actually gone through some experience, some learning science, some study habits course. Remember, because they're so smart. They made it all the way through medical school, they, they figured out how to take tests when they were 12. Like I did never thought about learning after that just, just had to absorb things. That's not what happens when there's not a test six weeks out, now you have to learn something, change your behavior in perpetuity. And that's not a skill that they had. So if you can build an instructional design or apply an instructional design model in which you understood the behavioral limitations of the learner in the moment, and also understood the behavioral limitations of that learner over time, scaffolding takes on a whole new definition. Right now, not just scaffolding content. I'm not trying to teach you multiplication before I teach you long division. I'm not trying to teach you long division before I teach you calculus. That scaffolding, scaffolding content, I'm actually just trying to scaffold the behave- behaviors. And so I played with this idea for a couple years, I wrote a book and in the process, this is when I left Pfizer in the process of writing the book, I talked to about 100 entrepreneurs in healthcare, IT, trying to understand how information was flowing through all the way from research to patient care, what the limitations of that were, and some of them — and this is three or four years after Facebook was around and prior to several the other platforms that you and I use quite frequently. And so this idea that information could flow much more efficiently through some of these new channels, if we also understood how people learned and we could connect the dots between these two different emerging fields. That's basically been my life's work for now 12 years since about 2008, 2009. Trying to figure it all out. I don't know if I figured it all out. But I think we're in a much better place now than we were then.

Alexandra Howson  32:02
And what's the book called Brian?

Brian McGowan  32:05
Oh, gosh, #SocialQI. And last thing I looked, last I looked, it was available on Amazon for $12,000 for an old copy. It's been out of print nine years, but occasionally they’ll have some old copies lying around. And so it was simplifying your healthcare, like if if we thought of ourselves, like what we need to do to learn where information lies. And, Alex, you know, what we as a country have gone through in the last two years with information and misinformation. There's an entire chapter in the book about the fact that just because you connect the pipes, so information can flow wherever you want it to flow. And just because you have changed what it means to be a publisher from being a controlled set of folks who control them, the message to everybody being able to publish their thoughts in real time and all the value and benefit of that social and collaborative learning experience. I think we're all pretty much aware that there's some pretty severe downsides if people don't think through it the right way. And so that was the message of the of the story is we, we could be in a very different place in healthcare by 2020. But if we don't do it the right way, I'm not sure we're going to be in a better different place by 2021. Oh my God, knowing doesn't equal doing especially when people are trying to get you to know things you don't need to or know things that aren't true. And so in the process of writing the book, and all these interviews, one of the entrepreneurs that I interviewed had asked me about some of the other research I was conducting. And I told him about this intersection of behavioral science and learning science. And he said, I think I can build a software platform that can do everything you're describing. And so that was 2012, 2013, we started this new endeavor. But if you think about it, I like this anecdote, too. To me. The maybe the most ubiquitous example of the relationship between behavioral science and learning science was serendipitous, but somebody at Microsoft decided that when you print out slides, there should be like five different ways you can print out slides. Do I want one slide per page, like, you know, the right to — two slides per page? What's that? What's the third option? Right? Do I want three slides per page with little black lines next to each slide that allows you to take notes. That's brilliant, in an unexpected way, it's brilliant. And I don't know that I've given a talk in the last 10 years where I have not handed out three up slides with the lines on the right, because Alex knows that the slides are asking her to write words down. That's what those little lines are there for. Alex knows that we want those words, those thoughts that you're writing down to be connected to the content that you're looking at, because when they're disconnected, they fade. It's great that I have this notebook that I look at once in the spring and once in the fall. But it's not related to the content that I was learning.

Alexandra Howson  35:18
Here's my notebook. And I'm just showing the notebook that I take to all my conferences,

Brian McGowan  35:23
On a on a, after a drink or two, you and I can sit down on a couch and talk about the strengths. And if you think about it, some of the weaknesses of that application of you externalizing your thoughts, it's good to document them. So what do the three slides do they, they really, they're a very visual nudge to the learner to write things down. And they create the connection beforehand. They don't solve the problem after the fact, right? Because you still either leave your notes, or you collect all these notes, and you go home from the meeting. And you still have to now make it through 300 emails that you've got to sort through that you didn't answer while you're at the conference. And so we still have a series of other behaviors. But that idea of that using a tool saying to the learner, your expectation is not just to listen to me. But it's to take that information in and begin to document it in a way that we know it’ll persist before it persists in your head. And that's, that's a really important lesson, I think people think, Oh, I learned that. And it's temporary. Like we know enough about the neurobiology, I know that it takes sometimes repeated three, four or five times before those nerves that fire together finally wire together. And if you don't have these other behaviors, scaffolding you while you're doing that, while you're waiting for that to happen, then it's just lost, lost. 

Alexandra Howson  36:50
So let's talk a little bit about the, the that concept of behavioral scaffolding because I, you know, I see in you, you, you curate, you curated this amazing kind of reading list of books that has kind of helped you come to your insights over the years, and a lot of them are from psychology and cognitive psychology, in particular. And psychology is not my background, sociology is my background. So that frames the questions that I'm about to ask next. Because when you talk about learning, and thinking, a lot of the scaffolding that, that I hear around thinking, are feeling the role of emotion in driving curiosity, and firing up some of those neurons in the first place, movement, the note taking, you're firing up particular activation, and the movement of the body, I think there's some work around this, a movement of the body itself creates these kind of embedding connections into the brain that help the kind of the cognitive process. And then the social and the cultural context. Alex only knows what the little lines mean, because there's a kind of cultural and social framework around, you know, what those mean, in a formal public or academic learning sort of context. So can we talk a little bit about how continuing healthcare education can take those kinds of insights to really support the translation of the cognitive things that happen? And kind of cross the threshold from the context in which the thinking occurs to the context in which the behavioral change has to occur? Because that seems to be the perpetual challenge for a lot of education, not only in, in healthcare, but I think I think we see that in a lot of different kinds of contexts. So does that question…? Would you reframe that? 

Brian McGowan  39:13
No, no, I, I can take a stab at it. But just as a reminder, you're asking a college football player who wanted to be an orthopedic surgeon

Alexandra Howson  39:22
you can't back away from it now.

Brian McGowan  39:25
about emotion. The idea of how, where emotion plays in all of this is certainly not my go to, but it's 

Alexandra Howson  39:33
It's really about what you mean, what do you mean by scaffolding? How can we how can we concretize that and build more viable kinds of scaffolding into education programs.

Brian McGowan  39:54
So I'll take a shot at it. I- There's some tremendous research about learning environments and test taking environments as a surrogate for learning versus performance environments, right. And so we know that that there's a stark uptick in performance on assessments if the assessment is delivered in a setting that's similar, identical to where learning took place. So there's a context, you, if you sat in the third seat in your high school classroom, and on test day, the teacher came in and said, Everyone switch seats, you can probably predict a 10 to 15% decrease in performance across the entire class, just because people were asked to move a foot away, or six feet away from where they were. So we certainly understand that context. Similarly, there's tremendous research. I think this book made my list: it's Adam Alter’s Drunk Tank Pink.

Alexandra Howson  40:57
Yeah, yeah, I have that

Brian McGowan  40:58
You'll be able to share the list in the show notes?

Alexandra Howson  41:01
Yeah, I was gonna ask if you please - open to that. Absolutely. I'll put that in the show notes. Because I think it's a, it's a, it's a marvelous list.

Brian McGowan  41:09
There, there are a- about just short of 50 examples in Adam's book about how easy it is to prime or frame a learning experience for the better or the worse. How to design a learning experience. And he would argue as many do that if you're not designing it intentionally, that you're designing it unintentionally. And some of the examples he uses is if you were to bring learners into any learning experience, and you were to remove the lampshade from a traditional desk lamp. So just the, the naked bulb turned on, brightly shining, and allow the learners to work through a task of some sort, something that has to do with creativity, brainstorming, that there's approximately a 20 to 30% increase in the number of brainstormed ideas that arise from the group. They'll persist longer, there's less likelihood that they'll kind of go through that negative or destructive shutting down different behaviors. And the one variable is this light bulb. Right? What's that mean? It means in certain cultures, the idea of a singular light bulb is a eureka moment. It speaks to ideas, it speaks to creativity. And so this notion of priming or framing is the ability to take something that has nothing to do with the educational content itself, nothing to do with the big screen behind the podium, nothing to do with, you know, the three up slides that you're handing out, but it's about changing the mental framework, the emotional state, in many cases, the, the mindset of the learner, and he goes on to explain like doing similar things with like an American flag, and how you can, you can create that negatively, like if you have a whole bunch of people in the room that are not American citizens, or in whose culture The American Way is a not a positive thought in their mind, then you can actually shut down their creative thinking you can shut down their recall, you can shut down their persistence in learning exercises. So there's a lot there. The idea of is trying to do something at scale outside an applied experimental setting is a challenge. I think what we would find is if you think of all the learning experiences that we build, that there are some the airplane hangar type learning experiences of 1000 person 2000 person, 5000 person, the primary job of those, the primary expectation or goal of those meetings is not effective learning. It's simply to state information into the ether. As a way — it's, it's a broadcast mechanism. And so I don't spend a lot of my time trying to understand how to solve those. Right? I think the questions that you're asking, those questions can be solved through facilitation, through experience sharing, through social learning, through context specific exercises. You know, we're, we're decades — as much as as Zuckerberg would like to say that the metaverse is going to change things soon, and simulations and this idea of rendering and — we're decades away from each of us as learners being able to overcome the extraneous load, I want to be in a simulation. But there's so much extraneous load that the learner has to create or overcome in creating the protagonist in those simulations. Does that make sense? Like if you put me in a simulation, and I'm sitting in a classroom and it's a basic roleplay, I've got to pretend. There's so much extraneous load in the pretending piece, that it becomes really hard, and the evidence would suggests this, it becomes really hard for us to extract all the value of a simulation. It's why airplane pilots train in airplane cockpits, like everything about it, except for the crash, except for the consequence, which is in and of itself a pretty huge but, everything about it is the exact same scenario. So what we're trying to do with knowledge learning —

Alexandra Howson  45:23
And that speaks to – 

Brian McGowan  45:25
Go ahead, go ahead.

Alexandra Howson  45:26
Sorry, I cut across you there. And that speaks to one of the characteristics of simulation, which is authenticity. And when you have authenticity and simulation, you know, some of the research suggests that that is a good kind of context and framework for learning. But I think I what's so interesting about what you're, you're saying is that, you know, we've seen this a little bit, a shift towards organizational learning, facilitated learning, experiential learning, how far away from that is the current field of continuing healthcare education, and does it need to move toward that more boldly, or, or keep tinkering at the margins?

Brian McGowan  46:15
I tend to see the world as the continuing medical education profession, that most of the people at the Alliance or at European Conference or the meetings that we go to, this community, I tend to see that the vast majority of that is — what can be expected from those experiences may not be as deeply rooted. And as a tip of the spear, as what can be expected from learning experiences, that are smaller group cohort, collaborative experiences maybe part of a healthcare system pulls an interprofessional conference. And, you know, on a separate session, you and I could debate the difference between being interprofessional and team based, because there's a lot of extraneous load in interprofessional, as well, it's great to have different voices in the room. But you still have different voices from different settings. And I don't know that we're advancing the ball far enough down the field there, it's when I'm sitting with the five other OR nurses and the anesthetist and the surgeon in that setting. I think you're truly seeing that social team-based learning. And so, so I think, I think we just have to have different expectations, right? From the airplane hangar to hour long on-demands to a small group workshop or breakouts to a mentoring and coaching, there are values, there are benefits of all of those things. I don't think that we can hold symposium and online sessions to the same standards that we hold a one-on-one coaching or mentoring kind of program. But we also don't have the resources to provide that gold-standard learning experience to you know, 900,000 physicians, and four plus million advanced practice clinicians just in the United States alone. So we've got to accept that there’s strengths and weaknesses and for each, however, whatever the the, the guns you're bringing to the fight are, or whatever the tools you're bringing to build education are, trying to optimize them with a balance of scale versus personalization. And I think that's just a critical, a critical decision, a critical check sheet balance we need to take with almost every decision we make, and it just can't be black and white. And I hear there was a big movement eight or nine years ago, that if — there should be no satellite symposium there should be no asynchronous on-demand, that everything we should be do should be like the small group facilitated workshops. Yes, they're better, no one's going to say that that's not a better way of educating it. But there are tradeoffs to those approaches. So I think in small clusters, people are doing that gold-standard stuff, and I respect and envy them. I think that there's a lot that we can still do to raise the bar for the scalable stuff as well. And that's whether it's scaffolding behaviors or whether it's scaffolding the emotional the, the, the non-cognitive pieces of it, there's things we can probably do. And that, that may have been the worst answer I could provide you at the longest amount of time. So check both of those boxes. Bad answer that took 12 minutes.

Alexandra Howson  49:39
no, I think it's yeah, I you know, I think it's just kind of testimony to — there are there are so many layers to unwrap in, in thinking about thinking and thinking about learning and feeling about learning, you know, all those all those things and the context in which learning takes place. And what we want to do at the end of that learning, what we want learners to do at the end of the learning, that's really the critical translational moment, isn't it? And thinking about moments, I'm conscious of our, of our time. So two things. First of all, I think there's another book there. I think, you know, in your spare time, something to, something to think about. But time to get your kind of crystal ball, in terms of, you know, where, where do you think the field of continuing healthcare education is? And where should it be moving toward?

Brian McGowan  50:39
I think the more we apply the, the standards of a profession, the faster we’ll advance. And so I, I gave a talk, almost 11 years ago now called The Unauthorized History of the CME Profession, and in it I questioned whether we are a community of employees, or whether we're truly a profession and if you look at almost any definition of a profession, it's a like-minded cadre of…: plumbers, carpenters scientists, like-minded, that share a similar collective intent and a shared praxis. So they are trying to accomplish the same thing. They are applying the scientific method with a shared set of tools to understand the realities that they're all trying to improve. And when you get those three things together like-minded cadre of scientists with shared practice and collective intent, then you move in much more accountable and, and efficient ways. When you have hundreds of people writing proposals that say this is the best form of x. And there's no way to compare apples to oranges then no one's ever accountable. And so as we start to measure more, as we get more into standardized approaches to the methods that we use, when we can — I share this anecdote yesterday, you know, even the scientific methods are changing dramatically what we're doing in cognitive psychology, Katie Milkman, and her team just published in the last 48 hours in Nature, a mega study where they had 30 different interventions to try to understand one single behavior, how do we get people to go to the gym more in 30 days? And how do we get them to persist in the gym regimen after 30 days. They tried, in a single randomized population, 30 different things. And they use the same exact measures at the end of the day. And then they asked a series of experts to predict which of the measures would be the most beneficial, and there was zero concordance between the prediction and the reality.

Alexandra Howson  52:54
I was just gonna say, I think I know where this is going. 

Brian McGowan  52:57
Yeah, yeah, like monkeys and darts. With less than, I think it was less than, than random chance was their predictions. And if we don't think that our profession is being limited, by those same “what's in this population here, over this time frame here, but it's this intervention there”, if we continue to say, “Let's measure online learning”, and not recognize that 15 forms of online learning are basically 15 different interventions, and they're not all created equal, and simulations are not all created equal. When we start to see the world through the eyes of a scientist with collective intent and shared praxis, then we can look at everything that we do. And it either takes us one step forward or one step backwards. And so if we continue to make progress with the outcome standardization project, if we continue to ensure that the thought leaders are the decision makers, whether it's at the ACC and Me whether it's at the Alliance, or whether it's at the, the head of a table at a grant review committee at one farmer supporter, if we can move the decision makers forward in their understanding, and that kind of scientist-think like a scientist perspective, if we can get the decision makers to move forward, then the rest of the community will eventually become the rest of the profession with a capital P, and maybe 5 or 10 years from now, we're in a significantly different place. I'm hopeful. I’ve seen, you and I’ve both seen progress in our careers. But I think I'd like to see- I don’t want to speak for you. I'd like to see that progress accelerate. I'll probably be doing this for a couple more years. I'd like to leave it in a better place than when I found it.

Alexandra Howson  54:34
Brian McGowan, learning scientist, facilitator, progressive. Thank you so much for sharing your expertise on Write Medicine.

Brian McGowan  54:43
Thank you very much, Alex.

Brian talks about his background
Entering the world of continuing education
Learning science as an intellectual field
Stumbling into thinking about thinking
Scaffolding behavioral change
Embracing different kinds of learning