Otolaryngol Clin N Am

40 (2007) 1323–1330

Lifelong Learning in Otolaryngology:

Self-Directed Learning
John M. Schweinfurth, MD
Department of Otolaryngology and Communicative Sciences,
2500 North State Street, Jackson, MS 39216, USA

Professors are fond of telling graduates, ‘‘This is just the beginning of

your education, not the end.’’ Nothing in didactic form approaches the
learning experience of the real world, in which there are no textbooks, no
lesson plans, and no teacher to fall back on. Many early decisions are based
on a teacher’s transplanted wisdom. Often the transition is abrupt; the
educational process up to graduation is based on a teacher-directed model
of learning, for which there is no direct continuity in practice. Currently,
there are multiple, instructor-led resources for long-term learning, including
opportunities for continuing medical education (CME) from annual
national and regional professional meetings, home study courses, audio
digests, and online reviews.
This article, however, is not about formal, teacher-directed learning
activities, such as lectures and CME. The reality is that instructor-led
CME activity, although valuable, represents not only an artificial learning
environment but also a relatively ineffective one at that [1]. Active engage-
ment in self-planned learning activities tends to be more effective than
passive learning, which commonly characterizes formal CME. Most lifelong
learning is problem specific and occurs in the context of real experience: the
clinic, on an Internet search engine at night, or over the phone with a col-
leaguedthose conversations that invariably begin, ‘‘I got this guy..’’ Life-
long learning involves finding and implementing solutions to everyday
problems encountered in the clinic, emergency room, and operating room
and on the wards. The process by which much of this education occurs is
via self-directed learning (SDL). According to Gibbons [2], a paradigm shift
in instruction is ‘‘teaching students to challenge themselves to pursue activi-
ties that arise from their own experiences, employing their own emerging
styles to find patterns of meaning and processes of productivity that lead

E-mail address: jschweinfurth@ent.umsmed.edu

0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.07.011 oto.theclinics.com
1324 SCHWEINFURTH

them to a high level of achievement and fulfillment. The prime imperative.is

not to enhance teacher-directed learning, but to develop a more student-
directed model.’’

What is self-directed learning?

Hammond and Collins [3] describe SDL as ‘‘a process in which learners
take the initiative, with the support and collaboration of others. For increas-
ing self- and social awareness; critically analyzing and reflecting on their sit-
uations; diagnosing their learning needs with specific reference to
competencies they have helped identify; formulating socially and personally
relevant learning goals; identifying human and material resources for learn-
ing; choosing and implementing appropriate learning strategies; and reflect-
ing on and evaluating their learning.’’ This humanistic characterization of
SDL implies a sense of social awareness and responsibility, self-actualiza-
tion, and the acceptance of personal responsibility for one’s own learning.
The acquisition of SDL is a complex process that involves numerous
skills and competencies relied on to complete challenges, such as medical
school and residency. Unlike the classroom setting, in which the emphasis
is on mastery of content, SDL emphasizes personal action taken to become
more productive. Testing is no longer an issue, but performance certainly is.
Many authors have identified SDL as essential to continuing education
efforts in adults [4,5].
Not everyone is ready to accomplish SDL, however, because certain traits
are essential for becoming a successful, productive person. Candy [6] synthe-
sized an essential character list from more than 100 such traits (Box 1).
Generally, SDL is not limited to specific settings but can occur as a part
of any process and include formal learning activities. Among Tough’s [7] fac-
tors are three common patterns in independent study: (1) a specified learning
need, (2) curiosity, and (3) general desire to learn. Houle [8] described three
groups of adult learners: (1) goal oriented, (2) activity oriented, and (3) learn-
ing oriented. Of these types, many practicing physicians clearly fall into the
first category, because they frequently embark on a learning project to
acquire new procedural skills or become familiar with new medications or
updates in coding and reimbursement schedules, for example.

The challenge model of self-directed learning

Possibly the most influential essay on SDL is ‘‘The Walkabout’’ by
Maurice Gibbons, which was published in the 1974 edition of the Phi Delta
Kappan [9]. At the heart of the essay is the story of two children lost in the
desert wilderness of the Australian outback. Facing certain death, the two
are found and cared for by a young aborigine on his walkabout, a 6-month
endurance test during which he must survive alone in the wilderness and
 LIFELONG LEARNING IN OTOLARYNGOLOGY 1325

Box 1. Skills and competencies of the lifelong learner

 Being methodical and disciplined
 Being logical and analytical
 Being reflective and self-aware
 Demonstrating curiosity, openness, and motivation
 Being flexible
 Being interdependent and interpersonally competent
 Being persistent and responsible
 Being venturesome and creative
 Showing confidence and having a positive self-concept
 Being independent and self-sufficient
 Having developed information-seeking and retrieval skills
 Having developed knowledge aboutdand skill atdlearning
generally
 Developing and using defensible criteria for evaluating learning

return to his tribe an adult. Gibbons surveys the ramifications of the story
from a societal standpoint:
‘‘The movie is a haunting comment on education. What I find most provoc-
ative is the stark contrast between the aborigine’s walkabout experience and
the test of adolescent’s readiness for adulthood in our own society. The
young native faces a severe but extremely appropriate trial, one in which
he must demonstrate the knowledge and skills necessary to make him a con-
tributor to the tribe rather than a drain on its meager resources. By contrast,
the young North American is faced with written examinations that test skills
very far removed from the actual experience he will have in real life. He sol-
ves familiar theoretical problems; he does not apply what he knows in
strange but real situations. His preparation is primarily for the mastery of
content and skills in the disciplines and has little to do with reaching matu-
rity, achieving adulthood, or developing fully as a person [9].’’
The walkabout model is applicable to the learning required by the prac-
ticing physician. First, it should be experiential and the experience should be
‘‘hands on.’’ Second, it should be a challenge that extends the capacities of
the learner. Third, it should be a challenge specific to ordeven betterdde-
signed by the learner. A productive learning experience depends on the
learner’s ability to make appropriate choices, but in most teacher-directed
situations the student is not called on to make any meaningful choices.
‘‘The test of the walkabout, and of life, is not what (the learner) can do
under a teacher’s direction, but what the teacher has enabled him to decide
and to do on his own [9].’’ Most importantly, the trial should be an impor-
tant learning experience in itself and should involve not only the demonstra-
tion of the student’s knowledge and skill but also self-awareness, flexibility,
and personal nature.
1326 SCHWEINFURTH

The ‘‘change’’ model

Fox and colleagues [10] developed a model of learning and change
based on 700 incidents involving more than 300 physicians. The authors
found that the most common forces for change were professional: a general
desire for competence or the perception of a changing clinical environ-
ment. Once a need for change is identified, the physician develops an im-
age of how the practice would appear after the change. Information is
gathered to help analyze the gap between existing skills and skills neces-
sary to complete the change. It is the process of analyzing and describing
the gap that provides the jumping-off point for planning, developing, im-
plementing, and assessing learning activities. The process of change in-
volves three stages: preparing to change, making the change, and
sustaining the change [11].

Learning through experience

The process of learning through experience has been described in Kolb’s
[12] experiential learning cycle.
1. Concrete experience: In the first stage, a physician may encounter an
unexpected situation that differs from expected practice (eg, a complaint
of hoarseness with a normal appearing larynx).
2. Reflective observation: After the encounter, the physician reflects on the
experience, performs an Internet search, consults with a colleague, or
perhaps takes no further action.
3. Abstract conceptualization: The physician combines the results of
reflection with any new knowledge gained to conceive of a possible
new approach that would theoretically encompass the problem (in this
case, a neurologic disorder such as spasmodic dysphonia or vocal
scarring).
4. Active experimentation: A new approach may be taken. In this example,
a videostroboscopy might be performed or a new diagnosis considered
and tested. The experience with the new approach (eg, findings on vid-
eostroboscopy) immediately leads to a new concrete experience and the
cycle begins anew.
Kolb’s cycle provides an excellent model for conceptualizing the learning
process a practitioner might undergo as a result of clinical challenges en-
countered on a regular basis. An abundance of adult learning research sup-
ports the role of experience and reflection in continuing education [13–17].
In reality, the process is likely to be more dynamic, complex, and interrupted
with fits and starts, dead-ends, misinterpreted experiences, and incorrect
conclusions. An awareness of the process assists the learner and educator
in designing and promoting educational experiences that allow for each
stage to occur and mature.
 LIFELONG LEARNING IN OTOLARYNGOLOGY 1327

Promoting self-directed learning

Although internal motivation for learning is more powerful and enduring
than external forces, near-term goals (eg, recertification and renewal of med-
ical licenses and hospital privileges) are the order of the day when time is
limited, as is always the case. Factors that may facilitate and combine these
processes ultimately are more productive and satisfying to the learners and
professional boards and licensing bodies.
Specialty literature, national and regional conferences, and other CME
activities may help learners identify gaps between needed skills and current
capabilities and help learners to visualize an image of change to see how it
might look to do something differently. Computerized learning modules and
portfolio projects may potentially bridge these knowledge gaps. Similar to
a teacher-directed learning experience, computer modules may serve to drive
Kolb’s learning cycle by providing prompts and asking questions that
require reflection or application of new knowledge. Online searches offer
access to specific sources of knowledge not readily available in texts. Portfo-
lio projects can serve to document the SDL processdfor refinement and
potentially for CME credit or recertification.

Identifying needs
Physicians respond to areas of deficient knowledge by referring complex
patients, having discussions with colleagues, and consulting the literature
[13]. These behaviors are typically stimulated by perceived deficiencies
from caring for a particular patient, having discussions, or reading. These
deficiencies, however, are often subjective and may not accurately reflect
actual needs. Objective needs assessment is needed to provide a more real-
istic image of knowledge gaps. Systematic assessments, such as performance
audits and outcomes measures, patient care benchmarks, billing and docu-
mentation audits, are examples of objective measures. Other examples
include independently reviewed portfolio projects and written or computer-
ized tests and problem-based scenarios. Regardless of the assessment strat-
egy used, it is important to allow the physician to develop a self-monitoring
strategy rather than merely respond to external events.

Computerized self-directed learning modules

Adult learning theory, including Kolb’s cycle and the principles of
SDL, depends on the developments of practical tools that help individ-
uals take charge of their learning and apply the theory to their own prac-
tice. As personal computers and the Internet have enjoyed growing
widespread use among physicians as essential resources, the potential
for their application in CME also has expanded. Although the full poten-
tial of computerized SDL has not yet been reached, several models are
available.
1328 SCHWEINFURTH

The maintenance of competence program is designed to encourage spe-

cialists to take charge of their own CME efforts [18]. The program has three
components: (1) A credit system to promote production of high quality, prac-
tice-based, educational programs. (2) A self-directed CME plan designed to
motivate individual specialists to record and critically appraise their CME
activities. (3) An annual, personalized CME profile. Physicians obtain
information in many ways (eg, reading, consultations, rounds, research),
but these activities are too numerous to record on a regular basis and rarely
lead to a change in practice. This information screening is defined as ‘‘general
professional activity’’ in the revised maintenance of competence program and
consists of scanning the professional environment for new ideas. Occasionally
information does capture the interest of the specialist, who might then explore
the area in more detail, which is known as ‘‘in-depth review.’’ These activities
are focused and goal oriented and should lead to one of the following
outcomes after completion [19]: (1) I will modify my practice. (2) I will wait
for further information before I modify my practice. (3) I see no need to
modify my practice.
The computerized evaluative learning tool is based on the adult learning
principles that learning should acknowledge prior experience, allow reflec-
tion, be participative, provide ownership, and be self-directed [20]. Users
enter data under four menus, depending on whether they have a specific
learning need, wish to apply new knowledge or learn from an event to
reduce future risk, or wish to analyze and learn from the emotions the event
caused. The four menus are as follows:
1. Educational need: The user starts with a learning need and the program
takes him or her through meeting the need and then applying the learn-
ing in practice.
2. Educational event: The user recollects a specific learning point and is
guided to apply it in practice.
3. Emotional response: This recollection allows learning from an emotional
experience to take place and enables a change in future behavior.
4. Significant event analysis: This process allows learning to take place after
a significant event in the workplace and enables the user to make
changes to minimize the risk of a subsequent event.
The computerized evaluative learning tool provides a learning structure
to enable physicians to recognize and document that learning has taken
place, be specific about what has been learned through reflection, and
then, if appropriate, act on the learning and apply it in practice.

Portfolio projects as a model for future recertification

The computer models described previously provide not only a framework
for SDL but also documentation of the process. This process and the accom-
panying documentation could potentially be used not only for CME credits
 LIFELONG LEARNING IN OTOLARYNGOLOGY 1329

but also for recertification itself. The Royal College of Physicians and Sur-
geons of Canada and several of the specialty societies, including the Canadian
Anesthetists’ Society, have developed the maintenance of competence pro-
gram project as part of the recertification process. The philosophy of the
maintenance of competence program is to develop a comprehensive CME
strategy that will motivate specialists to update their clinical practice
continuously.
Whether through the use of a software-based SDL computer module or
simply documentation on the computer, the use of portfolio projects as part
of the recertification process benefits physicians in several ways. First, it
encourages and formalizes the process of SDL. It is likely that the documen-
tation will encourage an increase in quality of the process and product and
the learning experience. Second, it encourages familiarity and skill with the
process so that each time SDL is initiated with less reservation. Finally, and
most importantly, the physician can be rewarded with specialty CME hours
or potentially with partial recertification credit, depending on acceptance
from accreditation bodies.

Introduction of self-directed learning in the undergraduate curriculum

The origins of Kolb’s work may be traced back to a famous dictum of Con-
fucius circa 450 BC: ‘‘Tell me, and I will forget. Show me, and I may remember.
Involve me, and I will understand [21].’’ As discussed at the beginning of the
article, the transition from teacher-led to learner-directed activity is unneces-
sarily abrupt. Given the rapid changes in medical knowledge and practice, the
need to keep abreast of the field is the one constant. But are graduates really
ready for SDL? Kell and Van Deursen [22] identified a preference toward
teacher-directed learning in average age learners and student-directed learning
in mature learners. The differences in learning preference persisted 6 months
after graduation. The results suggested that mature students enter the course
with skills that equip them to be more flexible in their learning, less dependent
on instructor direction, and more self-reliant. Although further research is
needed to identify which life skills are practiced by mature students and those
that would promote SDL if encouraged in younger students, activities that
promote involvement and active learning, as discussed in (article titled ‘‘Inter-
active Instruction in Otolaryngology Education’’, elsewhere in this issue)
would be expected to promote SDL in later life.

Summary
This article is intended as a primer and not a comprehensive discourse on
SDL and its role in CME. It is every teacher’s responsibility to realize the
impact of his or her teaching on learners so that the learners’ natural ten-
dency for self-direction, displayed in their personal lives, can be transferred
to their educational and working environments [23]. Similarly, national
1330 SCHWEINFURTH

specialty boards and associations, licensing boards, and governing bodies

should recognize the importance of continuous SDL motivated by an inter-
nal desire to improve rather than merely a reaction to external mandates.

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