Practice-based learning and improvement: a dream that can become a reality.
Systematically enhancing learning from experience (practice-based learning) dominates the teachings of Sir William Osler and adult learning theorists such as Eduard Lindeman, Malcolm Knowles, and Cyril Houle. Because of time constraints, most physicians have not implemented methods that systematically facilitate learning from day-to-day work, but improvements in information technology offer the promise of making systematic practice-based learning practical. At least four ingredients need to be incorporated to significantly enhance learning from experience: a database that makes it possible to study individual practices; methods for supplying short, quick answers to questions while seeing patients; a reminder system to avoid errors of omission; and the opportunity to discuss practice data with colleagues. Great progress has been made, but significant barriers still must be overcome before a majority of physicians will participate. In particular, methods of data collection must be simplified, the delivery of point-of-care information and reminders must become more automatic, and physicians must develop skills to make the discussion of practice data acceptable, stimulating, and not unduly punitive.