The theory of adult learning, identified and popularized by Knowles, describes four distinct qualities of adult learners: self-directedness, resourcefulness for learning from life experience, motivation from tasks required for the performance of social roles, and problem-centered learning (1). Knowles' adult learning theory was a theoretical cornerstone in the transformation of lecture-based curricula into self-directed, problem-based learning programs throughout North American undergraduate medical schools and formed the basis of continuing medical education (CME) models of life-long learning.
Adult learning has recently been challenged on both empirical and theoretical grounds. In his article, "The Adult Learner: A Mythical Species," Norman points to a lack of empirical evidence for the adult learner as intrinsically self-directed. Problem-based learning research shows that undergraduate medical students are motivated by grades and honors (2) and are more motivated by implicit short-term program agendas and final exam objectives than by personal interests (3). Problem-based learning approaches have not translated into enhanced physician competency, leaving the merit of adult learning theory in question (1). At the level of continuing education, the validity of adult learning theory has been similarly challenged. Research suggests that physicians decide to attend CME workshops based on their level of comfort with the material presented, rather than on relevance to practice or perceived knowledge gaps (4). Finally, in both undergraduate and continuing education research, the accuracy of self-assessment by adult learners has been notably poor (5, 6).
At the theoretical level, Norman cautions against the appropriateness of a self-directed learning model in undergraduate medicine, where learners cannot determine for themselves professionally guided core knowledge needed for competency (1).
The recent debate raises important theoretical and practical reasons to consider adult learning in the residency context. Compared to undergraduate and continuing medical education, postgraduate medicine features less in learning theory literature. As the most recently trained group of physicians, residents are responsible for providing the newest evidence-based treatments. Despite a university's efforts, it might not always be possible to access training resources for novel technologies. When the validation of a new treatment outpaces the availability of training resources, residents face the dilemma of needing to learn without formalized guidelines. For everything from laparoscopic techniques in the surgery to new psychotherapies in psychiatry, the potential exists for predominantly self-directed, problem-centered learning by trainees in order to gain competency in the new domain. The application of adult learning theory in the context of residency might foster residents' learning and have implications for its extension to continuing education.
This study explores the relevance of adult learning theory to postgraduate medicine using psychiatry psychotherapy training as an example. A survey of residents' experiences and attitudes in learning cognitive behavioral therapy (CBT) provides a window onto the influences on resident learning, factors which might range from program agendas and training requirements to qualities of adult learners such as self-direction, motivation from future practice and problem-centered learning.
Cognitive-behavioral therapy (CBT) is an ideal example to provide evidence for or against the presence of adult learners in residency as a new area of training demand in psychiatry residency outweighed by the supply of experts. Zaretsky notes, "Psychotherapy training of psychiatric residents has dramatically lagged behind CBT's growing acceptance and influence," (7) a fact reflected by the absence of any reference to CBT in training guidelines by the Royal College in Canada (8, 9) or by the Association for Academic Psychiatry/American Association of Directors of Psychiatric Residency Training Task Force in the United States (10, 11) at the time this study was conducted. The national guidelines have since been updated to include CBT in psychotherapy training. University training expectations and resources have also lagged. A survey of U.S. psychiatry postgraduate directors found only 54% of programs offer any training in this modality, and exposure is inadequate for minimum proficiency (12). At the university site of the present study, a fraction (8%) of the psychotherapy faculty is qualified to teach this modality.
The relative lack of CBT supervisors in psychiatry training programs today might be understood on the basis of an historical split in the psychotherapies between the "psychodynamic" and the "behavioral." The field of psychiatry has been dominated by the culture of psychodynamic therapies, originating from the late 1800s Freudian theory of the "unconscious." The field of psychology has been dominated by "behavioural" therapies developed later under the influence of learning theorists such as B.F. Skinner, who rejected the notion of the "unconscious" and focused on empirical observations and conscious thought. Some psychiatrists trained in dynamic therapy have reservations about cognitive-behavioral therapy, due, in part, to differences in theory and approach (13). According to Dr. Aaron T. Beck (14), CBT can appear "superficial" and "feel good" when compared to dynamic therapies (15).
There are now more than 300 clinical trials in CBT, including head-to-head trials with antidepressant medications, demonstrating its efficacy. CBT is cited as the treatment of choice for many disorders, including anxiety and depression (16), and is officially recommended for anxiety, depression, substance abuse, eating disorders, personality disorders and schizophrenia (17). The strength of the empirical evidence for CBT in treating psychiatric disorders is breaking down the historical obstacles to its presence in the field of psychiatry (14). The relevance of CBT is growing in the era of evidence-based medicine and managed care, which demands proven and cost-effective treatments (15).
The results of this survey on psychiatry residents' efforts to meet learning needs in CBT, in the context of relatively few teaching resources, suggest that the adult learner is alive and well at the level of residency training. The utility and implications of adult-learning theory in residency training are discussed.
The original purpose of this study was to survey psychiatry residents' attitudes and barriers to training in psychotherapy. Unexpectedly, the data generated useful evidence in support of adult learning theory. The result is a post hoc examination of learner attitudes and activities during the spread of a new medical content domain. It is set within the psychiatry residency program at one institution, and uses CBT as an example of a learning need for which training resources are comparatively limited. Residents' interests and activities in learning CBT are considered in order to explore questions about the applicability of adult learning theory to post-graduate medicine: How do learners grapple with the demand to learn new techniques with limited training resources? Do they behave as self-directed learners, with experience to identify the knowledge gap, motivation to learn and concern for future patient care? If so, what impact does adult learning have on postgraduate medicine, and does it create an internal push on the curriculum to change it?
This study surveyed 85 of 120 residents (71%) at a large urban psychiatry program regarding attitudes toward CBT training. The survey was developed through interviews with residents and with two cognitive-behavior therapy experts, and was piloted and revised with attention to its psychometric properties. The questionnaire consisted of 57 questions that required 10 minutes to complete. Residents' experience in CBT, barriers to training, and personal attitudes were evaluated. The questionnaire was distributed at an annual retreat attended by 60% of the resident body, and at three hospital-based lunches the following week, capturing an additional 11% of the resident body. Residents were identified by number rather than by name to preserve confidentiality.
The data were descriptively analyzed. Percent mean responses were calculated on a five-point agreement scale (strongly disagree=1 to strongly agree=5) or a three-point frequency scale (never=1 to frequently=3; very important=1 to not at all important=3). Where there were missing data, the mean response was calculated on the available data. Items missing more than 10% of the data were excluded. (Lowest average response for reported data N=74, or 91% of the sample). Where appropriate, when experience in CBT was needed to answer questions (i.e., "In your experience, how helpful is CBT to patients with the following disorders?"), results were reported only for subjects with experience in CBT (N=46) rather than for the entire sample in order to increase the validity of the results.
The return rate was 95%. There was an even distribution of subjects across all five years of training. A vast majority of residents were highly interested and motivated to learn CBT. Nearly all residents (99%), regardless of level of training, intended to occasionally or frequently use CBT to help patients in their future practices, 100% considered it clinically useful, and 98% perceived it complementary with other therapeutic techniques.
Consistent with the model of adult learning theory, reasons for seeking out CBT training tended to focus on personal interest (86%), motivation (81%), opinion of its clinical usefulness (68%) and personal bias toward the model (62%) (see t1). Only a minority considered training requirements a motivation for seeking training (44%). Interestingly, the 44% who considered training requirements a key motivation for seeking training also valued the treatment modality less and had obtained less experience in CBT at the time of the survey.
The most commonly reported difficulty in gaining exposure to CBT was supervisor availability (65%). Supervisor accessibility was also rated as a very important factor in residents' ability to gain exposure to CBT training (78%). Despite this apparent lack of resources, the majority of residents pursued learning in the domain, and 40% exceeded the basic CBT training guidelines by gaining more than 6 months experience or more than two clinical cases.
Residents were aware of the most recent evidence in favor of cognitive behavioral therapy. One hundred percent of self-directed learners in CBT (N=46) rated the therapy as somewhat or very helpful in treating depression, anxiety and substance abuse. Seventy percent of the sample rated CBT as helpful for psychotic and personality disorders (see t2).
Qualities of adult learners as described by Knowles appeared to be found in our residents. Personal interests and clinical relevance were more important to motivate learners than were training requirements. Despite a reported lack of resources, the majority of residents pursued self-directed learning in CBT, and 40% exceeded the basic training guidelines. Residents were aware of the most recent evidence in favor of CBT, and made evidence-based distinctions about CBT's effectiveness for patients with various disorders. The learners intended to use CBT in future practice to help their patients.
The results suggest that adult learning theory, which has been liberally applied to undergraduate medicine over the last decade, appears to apply to postgraduate medicine as well. In the context of meager evidence in undergraduate and continuing education literature, postgraduate medicine might represent a unique and fertile ground in which to study the adult learner.
Moreover, in accordance with Knowles' definition of adult learners, residents' motivation was derived from tasks required for the performance of social roles and from a problem-centered learning orientation rather than from the university's educational expectations, Royal College training guidelines and certification exam content. In the group under study, the local university guidelines for CBT training were rated by the majority of residents as unimportant in influencing the amount of CBT training received. Those who did rate training requirements as an important motivation for learning CBT (44%) valued the treatment modality less and sought less experience in CBT. This finding is consistent with adult learning theory in that those who value the treatment are more likely to be self-directed in their learning and to seek out additional opportunities to learn.
For the current content area being studied, Royal College guidelines were an unlikely motivational source since they had no requirements for CBT training. Regarding motivation from exams, unlike undergraduate medicine, the remoteness and relative absence of exams in residency over a 5-year period likely diminished their influence. Supporting this view, the official source textbook for certification exam preparation, Kaplan and Sadock's Synopsis of Psychiatry, 8th edition, discusses CBT on only 4 out of 1328 pages (<0.001%) (18). The survey findings point to self-direction, scientific evidence and future practice plans as the most important influences on learning motivation in psychiatry residents in this study.
Adult learners in this study appear to represent a source of pressure on the curriculum that historically has not been considered in curriculum development of postgraduate programs. Derived from a demand for education in the face of a shortage of resources, this force might be thought of as a "learner-driven" model of education change. In addition to the external pull of professional organizations, societal expectations and universities, the learners themselves appear to exert an internal push that changes programs. A learner-driven model of education has important implications for curriculum reform in that residency programs would be compelled to systematically track, monitor, respond to feedback and modify curriculum based on learner's needs. Needs-assessments currently are not systematically applied in postgraduate training programs.
Among those who were recruited for the study (81 of a possible 120 residents), the return rate was very high for a survey study (95%). It is not possible to know the bias represented by those who were not included in the study, due to their nonattendance at the conference or resident lunches where the survey was distributed. Hypothetical reasons for residents' absences could include being on call, vacations, family or other personal or work obligations, or the tendency to avoid social or work-related gatherings. One could assume that there was a random distribution of these various reasons across all 5 years of training since all were equally well-represented (equivalent percentage of each class). It is possible that nonattendees were less self-directed, which would have biased results toward the more highly motivated group of residents.
These findings are based on a study that was not designed to defend or refute adult learning theory. The results were reliant on learners' perceptions, were descriptive rather than prescriptive, and were restricted to a single university setting. Findings would be strengthened by replication of the results in various settings using a study designed to evaluate adult learning, with prospective follow-up on the impact of learners' perceptions on future practice. Nevertheless, these preliminary results are exciting in the context of the recent debate over the existence of the adult learner. Rather than being a mythical species, the adult learner is found alive and thriving in the fertile ground of postgraduate medicine.
In Norman's words, "Adult learning theory … served a useful role in putting the learner and his or her individual aspirations back into the teaching-learning equation" (1). The debate over the existence of the adult learner suggests that the nature and impact of learners' aspirations is yet to be discovered, and its potential is yet to be harnessed. Postgraduate medicine appears to be a good place to find self-directed learners, where future research on this topic might be directed to explore the activities and evolution of the adult learner. Adult learning theory might then serve the ideal role of matching evidence-based medicine and patients' needs with the learning aspirations of training physicians in order to optimize patient care.
The author thanks Drs. Richard Tiberius and Glenn Regehr, in the Center for Research in Medical Education at the University of Toronto, for their generous support, guidance, and assistance with statistical analysis and review; Drs. Ari Zaretsky, Zindel Segal, Daniel Greben, and Molyn Leszcz, in the Department of Psychotherapy at the University of Toronto, for their encouragement and clinical guidance; and Drs. Zaretsky and Leszcz for their editorial support. The author also thanks fellow residents Drs. Lisa Cvejic and Patricia Weibe for assistance with survey content, and Eman Leung at the Center for Addictions and Mental Health for assistance with data entry.