“Although it is my primary role to be a mentor and a teacher, I have learned that I get as much from the people that I’m teaching. And I know that kind of sounds cliché. But it is so true.” —Specialist Facilitator, Project ECHO

Rarely do we ask if — let alone what — experts or instructors learn from their participation in continuing medical education. But surely those who lead professional education programs — especially when such learning is highly interactive — also learn from professionals who are practicing in different contexts and possibly with different patient populations. But what do they learn? And from whom do they learn? We set out to answer these questions by studying Project Extension for Community Healthcare Outcomes (Project ECHO). Project ECHO is a telementoring continuing education model where specialists, often as part of a multi-disciplinary panel, facilitate case-based learning with healthcare practitioners from rural primary care practices, Federally Qualified Health Centers (FQHCs), nonprofits, and large healthcare systems. Similar to medical education classroom-based learning, residencies, and fellowships, Project ECHO uses case-based learning to provide guidance and feedback on best practices in patient care. Participants learn from one another as knowledge is tested and refined through a local lens. The underlying principle of Project ECHO is that when “all teach, all learn.”

Several scoping reviews about Project ECHO have documented learning by generalist primary care providers, family physicians and other community-based healthcare providers. In interviews with 60 specialists facilitating than 50 ECHO programs, we heard firsthand accounts about what they were learning and from whom they were learning. These specialists had titles including director of infectious disease, chief medical officer, clinician scientist, neurology program director and professor of pulmonary medicine. Of the 60 physicians, 53 shared learning episodes — descriptions about what they were learning from their ECHO engagement. This study was funded by the Robert Wood Johnson Foundation.

Learning About Community-based Healthcare

Engagement in ECHO was a reality check — helping to fill the research-practice gap. A pediatric neurologist with the American Academy of Pediatrics said, “They [generalist participants] are educating us about what works in the community. Like, ‘You know what? You told us to do that, but it didn't work at all’ or ‘We know you have that policy, but it doesn’t work in rural Alabama.’” Said an endocrinologist at the University of Chicago, “All of my research, all the things I’m academically involved with, involve Hep C. But every ECHO session I learn something about Hep C from a provider in the community about what’s going on with their patients; the real-world applications of data. I learn a ton. Now I have a broader understanding of the disease and the population we’re trying to help.” An endocrinologist shared, “We screen out a lot of patients who can’t afford to pay, who don’t have insurance … That’s why I appreciate learning what is going on out in the federal qualified health clinics.”

Learning About Whole-patient Care

Specialists learned about whole-patient care. “ECHO was an excellent experience for me because as a pediatric infectious disease doctor, I don't really know very much about dealing with patients with complex medical conditions,” said an M.D. with the Robert Wood Johnson Medical School at Rutgers University. “In this program we had family members, we had developmental pediatricians, we had rehab people. We would do the topic and then we would get input like, ‘What do you do in your practice if you have a patient who has a trach and they can't go to school right now? How do you deal with that?’ It was just completely different types of information than I was used to.” An M.D. at Texas Tech University Health Sciences Center who was facilitating an ECHO program about opioid diversion that included how to prescribe opioids for high-risk individuals, said of the experience, “We had a lot of good ideas from providers in the community about what to look for inside the home, mainly from the hospice community, giving us ideas on how to manage and control the flow of opioids, and when to cut ties, and what signs to look for.”

Interdisciplinary and Disciplinary Learning

The organization of healthcare can be a barrier to field-based and interdisciplinary learning. People tend to learn from others they perceive to be similar to themselves, including those trained in the same specialty. Participation in ECHO sessions helped to overcome such barriers. Specialists who took part as a panelist learned from other types of specialists. “The connection between adult neurology and pediatric neurology has strengthened through ECHO,” said a neurologist at the Queen’s University School of Medicine in Canada. “When these kids turn 18, they come to the adult practice. Just getting to know the pediatric neurologists a bit more really helps me understand where they’re coming from.” Specialists were also deepening their knowledge of their own specialty area. A dermatologist from the University of Missouri said, “I’ve been a dermatologist for 30 years and I still learn something every time we have a Derm ECHO. I could go on and on and on about all the things I’ve learned in Derm ECHO from my own faculty.”

Learning About Learning

The ECHO experience also helped physician facilitators to improve how they learn and how they teach — a pedagogical effect. Physicians were learning to listen to participants about their learning needs — not what the physician facilitator wanted to discuss. One reproductive health specialist at the University of Colorado Anschutz Medical Campus said, “They [participants] need to teach me what they need to know, because I don’t know where their knowledge gaps and where their challenges are.” We heard from many physicians that listening was a means to learning. An addiction specialist said, “There are things I really like to talk about and get excited about. I have to catch myself and think, ‘Wait a minute, I want to hear what other people have to say,’ and take a step back and not answer the question or provide an answer. There needs to be some silence and then people reflect and think and come to their own conclusions.’” 

Implications

Medical specialists who lead ECHO sessions are learning from community-based practitioners about conditions that are demonstrably different from their own and about types of patients that they may not regularly see. They are learning from social workers and healthcare providers about whole-patient care — attending to the social determinants of health. From other medical specialists, they are learning about complex medical care for complex patients and deepening their specialty knowledge. Specialists are also learning about learning from learners — practicing humility as they focus on what the learner needs and less on what they know.  

Why does this matter?  For one, when encouraged to think about what they’re learning, specialists might also pause to think about their research. Is it sensitive to contexts of practice different from their own? How might it change to address the contexts described by practitioners? They may also pause to consider how they care for their patients. Are they more likely to ask about conditions in the home? Consider the complexity of care and who is providing that care? Acknowledge their own knowledge gaps? Lastly, time to reflect on how they learn and help others learn has implications well beyond the ECHO session. They take this knowledge into all classrooms and teaching moments, thereby influencing future physicians and how they learn and help others to learn. 

By expanding our focus on who is learning to include what “teachers” learn and from whom they learn, we can begin to frame Project ECHO, and other continuing medical education programs, as continuing professional development for medical specialists leading sessions as they, too, further develop their own clinical reasoning. All of which is likely to make a stronger argument for the continuing support of medical specialists to “volunteer” their time to engage as specialists in ECHO sessions.