Adult Learning: Observations from the Sidelines

By Marcia Jackson, Ph.D., CME by Design

As educators who design and oversee the delivery of continuing professional development activities for our healthcare learners, many of us are familiar with the principles of adult learning. The Alliance for Continuing Education in the Health Professions (Alliance) has identified and codified the importance of understanding these principles as an important competency for our profession: “Competency 1.1: Apply Adult Learning Principles to CEhp Activities/ Interventions and Overall Program Planning.”

The purpose of this article is not to replicate what you can find elsewhere, but rather to share my observations about adult learning principles that I have made throughout my career. For 14 years, I oversaw all the continuing professional development activities of the American College of Cardiology (ACC). During that period, I stood on the sidelines of hundreds of learning activities, watched our audiences and listened to our speakers.

Engage and Motivate the Learners
The Maintenance of Certification “study sessions” were among the most engaging learning activities that I have observed. During these sessions, two extremely knowl­edgeable faculty members led the learners through board-type, multiple-choice questions. The questions were posed one-by-one, and the participants initially answered each question using an audience response system. After the responses were tallied for the question—and often there was a good deal of diversity among the answers—the fac­ulty members led a brief, lively discussion that resulted in a greater understanding as to why the correct answer had been so designated. Many key principles of adult learning were deployed in this single activity:

  1. The learners were active participants.
  2. The questions comprised brief cases that related to the learners’ clinical practice and to which they were asked to apply their knowledge.
  3. Feedback was immediately provided, both with respect to each learner’s individual response as well as to the comparative responses among the group.
  4. The anonymity afforded by the audience response system provided a “safe haven” for learners to answer questions incorrectly.
  5. Learners were goal-motivated, as at the conclusion of the study session they could gain points toward maintaining their board certification.

Integrate New Information with Learners’ Existing Knowledge Base
Every year during the holiday season, the ACC held a large symposium in New York City. The format of this symposium was predominantly lecture-based with accompanying slides, and the learners had an opportunity to submit questions, some of which were answered by the faculty. The overall topic selected each year was timely and relevant to clinical practice. The director was an acknowledged expert throughout the profession, and the faculty members were known experts as well. The faculty summarized the latest research on the identified topic and integrated these findings with the learners’ existing knowledge base, placing particular emphasis on the application of these findings to clinical practice. The activity took place in a large, darkened hotel ballroom, with two to three large screens that enabled the audience to see the speakers and the slides.

This symposium was, and probably remains, one of the most popular and best-attended ACC activities. By all accounts, this program seems to defy what we know about adult learning, and yet the audience was attentive through­out. I concluded that lectures can continue to play a role in supporting adult learning, as exemplified by the principles deployed in this symposium:

  1. The content was related to the learners’ current clinical experiences, and they wanted to hear the experts’ perspectives on these experiences.
  2. The latest research was provided by experts who integrated this information into the learners’ existing knowledge base.
  3. Learners’ reflections on their own practice in light of these experts’ perspectives was undoubtedly taking place though not directly addressed during the program.

When an audience is very interested in the topic and has an identified need to gain the latest information from experts, a lecture-based program is often the most efficient way to deliver what is needed. This is especially true for new and unfolding scientific research, where the implications for clinical practice have yet to be determined or they provide an important update to current practice.

Establish a Knowledge Base for New Information
I learned a great lesson from the sidelines during the mid- 1990s as the human genome was being unraveled. One of the ACC’s faculty members was deeply enthusiastic about its implications for cardiovascular care. His eyes would light up as he spoke and he swept me along with his enthusiasm, although I hadn’t the slightest idea what he was talking about. I observed the audience as he spoke in several programs and saw that the learners were simply not engaged, despite his expertise and enthusiasm. Upon reflection, I arrived at two conclusions:

  1. The content was premature for the learners. They simply could not see the implications of the human genome findings at this stage for their own clinical practice and couldn’t determine the relevancy of this new information.
  2. This new knowledge was just that for most of the audience: new knowledge. Their own medical training had not resulted in a foundation to which these new findings could be linked.

Practice with Feedback Is Essential to Develop Skill in Pattern Recognition
Pattern recognition is important in the practice of med­icine. I once asked a leading expert in interpreting heart rhythm disturbances how he had acquired such expertise. He answered: “I listened to normal hearts every chance I had during my medical training. Then I could interpret what was abnormal.” Important adult learning principles were at play here:

  1. Skills and pattern recognition require considerable practice with feedback. It takes time and many repetitions to acquire expertise.
  2. This expert identified and pursued his own learning goals during his medical career.

Learners’ Reflection and Recognition of Attitude Toward Patients
Lastly, how do we get our audiences to reflect on their own attitudes toward patients and the implications of these attitudes for their clinical practice? Knowledge and skills are comparatively easy to address in our learning activities, but what about attitudes?

A leading faculty member in the field of addiction med­icine tackled this as the very first activity in a day-long, small group-based workshop. The stimulus for attitude acknowledgement in this case was playing a brief segment from the Hollywood film, “Leaving Las Vegas,” in which the main character, Ben, is on an increasingly downward spiral due to alcohol substance abuse. It was tough to watch this segment, as we could see what was happening to Ben and the consequences for him. After the film segment concluded, the learners shared with their small group their attitudes and feelings about Ben during this film clip, us­ing prepared questions to guide the discussion. The session concluded with the faculty member drawing out in the large group the learners’ affective responses with sensitivity and understanding. Here, too, principles of adult learning were being applied:

  1. Learner self-reflection is stimulated through a mediated example and then supported through small group discussions with prepared questions.
  2. The faculty member creates a safe environment in which a difficult topic can be openly discussed.

These are a few of my observations, which depict a single event in each case. There is much for us as adults to learn about how we learn. An outstanding synthesis of many aspects of learning, instructional design and outcomes assessment can be found in the journal article by Moore, Green and Gallis, “Achieving Desired Results and Improved Outcomes: Integrating Planning and Assessment Throughout Learning Activities.” I keep this by my desk and refer to it often. We are fortunate as educators to be able to work with so many dedicated health professionals who not only lead our learning activities but also participate in these activities. Collectively, we improve patient care, and that is the ultimate outcome of adult learning in the health professions.


  1. Moore DE Jr., Green JS, Gallis HA. Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. J Contin Educ Health Prof. 2009;29(1):1-15.


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