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04 Jan 2022 2:12 PM | Anonymous

Case Study in Blended Learning and Interview with Gary Smith, PhD
Column Editor: Vjeko Hlede, PhD

This column aims to provide insight and practical information on the impact of e-learning on CME/CPD and the latest trends in technology available to enhance the online learning experience. 

Blending Learning Formats – A Story on how Baking a Cookie and Impactful Learning Interrelate                                                                An interview with Gary A. Smith, PhD by Vjeko Hlede, PhD

For anybody interested in CPD enhanced by implementation science, Gary Smith barely needs an introduction. As a Professor in Organization, Information, and Learning Sciences and Associate Dean for Continuous Professional Learning at the UNM’s School of Medicine, Gary co-authored a chapter in the latest “CME/CPD bible” Continuing Professional Development in Medicine and Health Care: Better Education, Better Patient (Rayburn, Davis, & Turco, 2017). He is the author of many papers focused on the interaction between faculty development, learning research and theory, and how to blend various learning formats to deliver successful practice change. Professor Smith also serves on the Academy Committee on Faculty Development.

Blended learning comes with many well-documented opportunities for improvement. With each of these opportunities comes the chance to make an error. In this article, Gary discusses ideas that may help us blend the CPD formats better with Vjeko Hlede. The second part of the article contains a UNM case study of how flipped classrooms—a blended learning modality—can deliver engaging, impactful CPD.

Vjeko Hlede: Thank you very much for sharing your case study and agreeing to this CE News interview, Professor Smith. Please allow me to start by reflecting on how I got familiar with your work. I became interested in your work in 2017 when the book CPD in medicine and healthcare (Rayburn et al., 2017) was published. I was impressed by your chapter (Smith & Stark, 2017) in the book. I was doing a Ph.D. at that time, and the chapter was foundational for my research. It is great to meet the author of that work. My favorite paper of yours is the essay where you use the metaphor for baking a cookie (Smith, 2015). Can you tell me more about the baking a cookie metaphor and how it can explain the challenges we face in CME/CPD offices?

Gary Smith: The essay where I use the cookie-baking metaphor refers to casual bakers who follow a recipe provided by someone else but maybe do not have much baking knowledge or skills. And so, if the recipe fails to create tasty cookies, perhaps because of some inappropriate adaptation of the recipe or lack of tacit baking knowledge, there's little opportunity for correction and improvement.

A more capable baker understands all of the ingredients and the steps in the process. He can learn from mistakes, innovate that recipe, and develop something very positive and different. The metaphor explains what faculty needed to know to teach well. It was written for faculty developers to think more about how they need to help teachers. Teachers need more than just lists of learning formats and activities. They need to understand how to use them, why they exist, and how various learning formats interact. The metaphor is equally valid in the CPD context. CPD staff can also benefit from thinking deeply about what they know about learning research.  Are they just following recipes and selecting from lists of learning formats? If you don't know why the recipe works or fails or how to adjust but still get that tasty outcome, you are just a line cook and not a chef.

Vjeko: Your paper argues that all faculty should be scholarly teachers. I wonder how we can implement that. And what about CPD professionals? Do CPD professionals need to be scholarly?

Gary: I feel that the CPD professionals involved in the design and implementation of the learning activities or who consult with the physicians and others who come to the office to create those activities should be taking a scholarly approach.  I draw that definition from higher education, where scholarly teaching refers to using research-based practice when designing, implementing, and assessing learning. As with any field, that means constantly updating knowledge and competence.

“Scholarly” and “scholarship” sometimes get confused. Scholarship involves disseminating what is learned, which is an important element of CPD. If we say that CPD professionals should take a scholarly approach, they consume what is disseminated about learning and transfer it into their practice. That's where I think this idea of scholarly teaching could be translated toward CPD in terms of scholarly approaches to the design, implementation and assessment of learning in our activities.

Vjeko: I wonder whether we could use the metaphor to tackle complexity better. The complexity of CPD seems to be a big elephant in the room. Our world is made of complex systems. Healthcare is probably the most complex system we have ever created. The tricky thing with complex systems is Donella Meadows (2002) explained that we can never fully understand them or control them. However, we can learn how to dance with them better. Can the cookie-baking metaphor help us learn how to dance? 

Gary: Yes. If we go back to the cookie-baking metaphor, we sometimes assume that we understand all the variables that determine the baking outcome. However, there may be variables we're overlooking or ones that are entirely outside our control, at least at the moment. So there's a certain amount of vulnerability and humility that goes into what we do. We must be aware that many circumstances aren't just complicated, but they're complex, and we may not have our hands around all the issues that will lead to success or failure. That points out how we in the education world tend to focus on learning designs and our interactions with learners, and we may lose the sense of the system in which everything is taking place.

That is a considerable opportunity. The system often has more control over the outcome than the learning we design. Therefore, better alignment with the complexity of the system may improve impact of the learning we support.

Vjeko:  So we have to think about systems and how to extend our reach. I'm wondering if we can use networked learning as a tool to build community and reach some of the things that have been traditionally out of our control. Networked learning is collaborative technology-enhanced learning where learners are situated in their unique local context and connected with resources, teachers, and other learners. Networked learning is often blended with face-to-face learning.

Gary:  Networks are important. Technology can enhance them, but they do not necessarily relate to the use of technology. Networking is what communities of practice are about. It's about people who have shared interests and are facing shared challenges and problems, who say, “We need to stay in touch. We need to share our ideas.” When we find something that works, we share that. When we find relevant information, we have a place to collect and curate that for everyone's mutual benefit. Those fit into normal ways people work and learn in their working environment. It is through the networks of people that they establish.

Vjeko: And, in that context, I wonder what SACME can do to support the change?

Gary: One thing is to encourage CPD providers to pay attention to what's going on in the broader realm of professional learning and development outside of educational institutions. Education is not the same as learning.

Education refers to formal scheduled experiences based on objectives created by the presenters and facilitators responsible for assessing the outcomes. That's very much the CME tradition. It fits into many of the ACCME activity types. In educational institutions, we tend to immediately think that, if there is some gap in performance or knowledge, all we need is a lecture on that topic, a webinar, or a conference.

Decades of research focused on learning in general and learning in a variety of workplaces show that professional development and learning mainly occur through learning on the job. Learning often takes much more informal approaches. That often includes communities of practice. This is why the non-academic learning and development community talks about this as creating resources rather than courses. And that rhyme speaks to the idea of supporting those dominant informal learning approaches. The focus is more on microlearning and performance support modalities than courses and enduring materials.

And here's where I think SACME could potentially take the lead and the scholarly support of learning by saying, “You know we're just a subset of professional learning and professions in general.” If we take a more holistic view and check what the nonacademic world and other professions are doing, we learn that it's not about signing up for webinars and sitting in conferences. We've been trying to do that here in the UNM. We've been focusing on on-demand, just-in-time-learning resources and smartphone-accessible web apps that support learning and performance in the flow of work and at the point of care.

Vjeko: When you talk about solutions, is it just about resources or about resources and networks? And, if we need both, how can we combine them?

Gary:  Relationship between professional development and networking is an exciting topic. Networks are arising in two different ways. There are networks and communities of practice that evolve utterly independent of anything the professional-development office does because they naturally and organically grow in the workplace.

They also do arise through professional-development activities. We see this associated with some faculty development or research-focused events. For example, we see that in situations when you draw people together for learning events, particularly folks who otherwise might not interact very much because they're from different specialties or separate locations. When they come together to learn around a similar topic and develop connections, they form a community, a network that evolves out of those events and can persist.

They can continue to create and curate information within the network and generate resources that the CPD program is trying to make accessible to everyone. In that sense, those networks can develop resources and feed them back into the CPD office to help disseminate more broadly, rather than to see the CPD offices as a single hub with all the spokes coming out.

Vjeko:  When we talk about the benefits CPD offices and programs can gain from networks, can we use technology or a specific process to better support that? For example, as the SACME technology group, we contemplate which technologies/processes we can use to support SACME as a community of practice.

Gary: Networks and communities of practice create and curate information. Therefore, having central resource locations would be excellent. For example, a type of MedEd portal equivalent for CPD could be very helpful, even if it wasn't intended to have a rigorous peer review and so forth, as the MedEd portal has.

Vjeko: COVID has provided a strong push from traditional face-to-face teaching toward technology-enhanced learning modalities. I'm wondering, in your opinion, did we make sufficient change? To use the cookie metaphor, are we using the technology to improve our recipes, or are we using new tools (technology) for cooking the old recipes? 

Gary: I think it will be beneficial to research what CPD providers and SACME as an organization did do during the pandemic lockdown and how they see that persisting. I do not know what all the CPD providers did during that lockdown and what will stick for the future. However, we can recognize one underlining mechanism.

When you have to shift gears as quickly as we did, it is natural to try to reproduce the in-person experience with a similar virtual experience. You respond to an emergency. So you are not in a position to think about how to completely redesign the learning experience using the technology or thinking about the differences of having participants remotely. You're just trying to take what you've become comfortable with. Those are things that you've already organized, you have an agenda for, and you want to create a similar experience virtually.

To use the cookie analogy, we have been using the new tools intensively. We have become proficient with the new tools. However, we are still cooking quite traditional recipes.

Vjeko: So there is an opportunity to extend our cooking repertoire.

Gary: No doubt. We have the technology. Educators and learners got used to technology-enhanced learning, and we have an obvious need. That creates a good environment to blend the ingredients in a new way and innovate. 


Meadows, D. (2002). Dancing with systems. The Systems Thinker, 13, 2-6. Retrieved from https://thesystemsthinker.com/dancing-with-systems/

Rayburn, W. F., Davis, D. A., & Turco, M. G. (2017). Continuing Professional Development in Medicine and Health Care: Better Education, Better Patient Outcomes: Lippincott Williams & Wilkins.

Smith, G. A. (2015). Why college faculty need to know the research about learning. InSight: A Journal of Scholarly Teaching, 10, 9-18.

Smith, G. A., & Stark, A. (2017). Enhancing continuing professional development with insights from implementation science. In W. Rayburn, D. Davis, & M. Turco (Eds.), Continuing Professional Development in Medicine and Healthcare: Better Education, Improved Outcomes, Best Care. Philadelphia, PA: Wolters Kluwer.

Case Study in Blended Learning at the University of New Mexico, School of Medicine, Continuous Professional Learning Office (CPL)

By Gary A. Smith, PhD

Blended learning activities.   Since 2018, CPL (the CME/CPD office of the school of medicine at University of New Mexico), has offered the majority of its faculty development-in-education workshops (CME courses) in a blended format.  Topics include:

  • ResearchBased Practices to Improve Your Didactic Presentations
  • Learning in Small Groups: How to Make It Work
  • Using Feedback to Take Our Learners (and Ourselves) from Good to Great
  • Up Your Teaching Game: Use Evidence Based Learning Principles to Build Success and Satisfaction into Your Teaching
  • A Toolbox for Effective Clinical Teaching
  • Integrating In-Person and Online Teaching and Learning

Each of these courses is offered at least twice per year as a separate CME activity.  We adopt the use of the term “blended” as it has been widely established in higher education and recently reviewed by: Saichaie, K. (2020). Blended, Flipped, and Hybrid Learning: Definitions, Developments and Directions. New Directions for Teaching and Learning, (164), 95–104. https://doi.org/10.1002/tl.20428.

Learning format.  Participants complete approximately one hour of self-paced, on-demand learning through online multimedia and assignments that include completing an online assessment.  Completion of the online assessment is the required “ticket in the door” at the scheduled in-person learning event.  The in-person components range in duration from 1 to 2 hours.  The interactive multimedia elements provide foundational knowledge that is utilized during highly interactive in-person sessions.  Therefore, the general approach compares to the flipped classroom model.

The multimedia elements and assessments are accessed through the Moodle learning management system in the CPL site called Just in Time Learning (JiTL).  Each JiTL page is an on-demand performance-support and microlearning resource that educators can access at any time, any place.  Selected elements of applicable JiTL pages are explicitly assigned as the online component of each blended course.  (To review a sample of JiTL, see text box below.)

HSC Moodle: Continuous Professional Learning

Just-in-Time Learning. Informational webpages, videos, take-away resources, and more for medical educators. Click on the blue title, above left, and then select "Self-Enrollment" to access the web pages.


Target audience.  Most participants in the blended courses are School of Medicine faculty who teach in the UME, GME, and health-professions curricula.  Additional enrollees include faculty in nursing, pharmacy, biomedical sciences graduate program, residents/fellows, and biomedical sciences PhD students and post-doctoral fellows.  A few participants each year are designers of CME activities and/or training and development functions within the health system.

Advantages and challenges.  Event evaluations show that participants like the blended format mostly because they can schedule a shorter time commitment for the in-person learning and pursue the online learning at their pace and as they find the time.  From a learning-design standpoint, the blended format supports the spaced-learning and testing-effect principles advocated from cognitive science research.  Facilitators can use the assessment results to tailor the in-person session to focus on specific learning challenges among the learners.  As the facilitator for many of these courses, I can attest to a much higher level of engagement and interactivity that is generated when participants arrive primed with both leveling knowledge and questions.  The only challenge has been to continually remind participants to complete the online learning prior to the in-person session.  Nonetheless, we have turned away only about 6 registrants among 200-250 enrollees per year over the past 4 years because they did not meet the preparation requirement. 

Some planners may view the time involved in creating the online modules to also be a challenge but we don’t at UNM.  Following best practices in learning and development, we know that most people learn not during scheduled courses and other events, but by consulting concise knowledge sources and performance supports in the flow of work.  Therefore, we put a high priority on developing the JiTL’s and then leverage them for the blended workshops.  This approach maximizes the impact of the effort expended to develop online multimedia and resources.

Evaluation.  We use the same evaluation forms for the blended courses as we do for fully in-person faculty development courses.  These evaluations include retrospective pre/post surveys and commitment-to-change queries (we also send email follow ups on commitment-to-change responses).  Results for blended and fully in-person courses are comparable.  Learning in either format has led to observe changed in teaching performance, but there is higher attendance in the blended events, probably because of greater access through reduced in-person scheduled learning.

Lessons for CPD practice.  Research on blended (flipped) learning in higher education should be broadly applicable to CPD practice.  The ability for learners to engage with foundational knowledge at their pace and then engage interactively when in person has clear advantages for advancing competency and performance.  We increasingly encourage our CME-activity planners to adopt similar approaches for healthcare-provider education.  We will likely deliver blended courses in quality improvement and patient safety in late 2022.

Gary A. Smith, PhD is Associate Dean for Continuous Professional Learning, the CME/CPD office for the University of New Mexico, and a SACME member. 

Vjekoslav Hlede, PhD is a Senior Learning Management Specialist with the American Society of Anesthesiologists, Chicago.

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