The Science of Motivation and Behavior Change – Episode #4

In this episode we are digging into The Science of Motivation and Behavior Change, and here are our Big Three Takeaways:

1. Knowledge rarely leads to action
2. Action is a product of motivation to change, ability to change, and critical triggers that spark, facilitate, or signal a behavior
3. BJ Fogg and others have provided us with invaluable tools for understanding these elements and how we must leverage them to engineer change

Our community seems generally aware that to drive behavior change one must be appropriately motivated. This is not a simple task and here is a great overview from Daniel Pink:

We now know far more about what types of motivations work best – and intrinsic motivation is far more powerful than extrinsic motivation

Extrinsic MotivationIntrinsic Motivation


More recently intrinsic motivations have been further explored by Fox and colleagues – we must, as educators understand perceived needs!

Intrinsic Motivation - Actual Vs Perceived Needs

In 2012 while he and I were both speakers at the first Medicine X conference at Stanford, I had the pleasure of first hearing, and then spending some time chatting with BJ Fogg – Dr Fogg is a behavioral scientist at Stanford University. In 2009, Dr Fogg began sharing what he refers to as the Behavior Change model. Here is just a bit of what he describes,

This paper presents a new model for understanding human behavior. In this model (FBM), behavior is a product of three factors: motivation, ability, and triggers, each of which has subcomponents. The Behavior Change model asserts that for a person to perform a target behavior, he or she must (1) be sufficiently motivated, (2) have the ability to perform the behavior, and (3) be triggered to perform the behavior. These three factors must occur at the same moment, else the behavior will not happen. The Behavior Change model is useful in analysis and design of persuasive experiences. The Behavior Change model also helps teams work together efficiently because this model gives people a shared way of thinking about behavior change.


To simplify Fogg’s work think in terms of the relationship between motivation, ability, and triggers!

Fogg's Equation

Fogg and Triggers

Fogg and Ability

Fogg and Simplicity


Finally, before we end – a complementary field of behavioral science study referred to as Nudge science or Theory has emerged over the past decade. And it might help for our community to understand its impact on behavior change too.

In 2008 Rich Fowler and Cass Sunstein introduced Nudge science to the masses with their landmark book called Nudge. In their words,

[a nudge] is any aspect of choice architecture that alters peoples behaviors in a predictable way without forbidding options or significantly and changing their economic incentives.


Nudge Book

Nudge science focuses on creating environments that make it easier for behaviors to change. Implicit in this emerging field is the reality that we, as humans, find it nearly impossible to consistently make rational decision – we struggle to balance short-term and long-term benefits and 9 times out of 10 we will take the easy way out….and we, as designers must account for this with effective nudges! For example,

Nudge Staircase

Nudge Alarm Clock

I have put together a primer for Nudge Science and if you are interested the following may provide some invaluable references:

In brief, the basic idea of Nudge Science is that humans are unrelentingly irrational. As a result, our choices are often neither rational or constructive – worse yet, our everyday choices are usually just the opposite. We struggle to balance long-term and short-term benefits and risks, we are more in tune with negatives than positives when reflecting and more in tune with positives than negatives when forecasting…and this undermines our lives, moods, and careers more so than just about any other element of ‘being human’….The research behind these statements has been masterfully summarized and explored in the following works:

To help construct a practical value proposition – this NY Times article from 2013 is a great place to start: Britain’s Ministry of Nudges 

And, just to end with one, more analytical perspective – check out the work of Stanford professor BJ Fogg. I love Dr. Fogg’s work because of how simple he has connected decades of research into Behavioral economics (Motivation), Adult Learning (Ability), Nudge Theory (Triggers)…B = M x A x T!

Finally, to connect these dots – as educators we must understand that learning alone will rarely lead to the behavior changes that are needed in the provision of the highest quality healthcare. But even more importantly there are critical behaviors OF learning that we must drive to support our learners as they engage in continuing education. From our research over the past 4 or 5 years, triggers and nudges have emerged as a critical piece of the Learning Actions Model and educators must leverage these devices to ensure that learners effectively learn!

New Learning Actions Graphic


The Natural Learning Actions – Episode #3

In this episode we are digging into new research that has lead to the development of the Learning Actions Model and here are our Big Three Takeaways:

  1. Much of what this community has come to believe about Adult Learning Theory is based on an assumption
  2. By demonstrating that this assumption is false – we have identified a critical new opportunity to mitigate the extraneous load of learning and optimize educational outcomes
  3. The new instructional design framework known as the learning actions model provides a roadmap for how to effectively leverage this new understanding in your educational planning

We tend to see learning as an entirely cognitive process – information appears in our sensory memory, if it intrigues us or confuses us it moves into working memory – which is quite limited – and then we struggle to create our own schema connecting new information to prior experience and knowledge so that we can create the networks that form the long term memory.

There’s been decades of adult teaching theory that’s been designed to explore how to make this cognitive process more effective. But what if it’s not enough?

What if all the time and effort and research that’s gone into understanding the cognitive parts of learning is overlooking a critical assumption that we are ALL making that undermines that process of teaching and learning? The assumption is… that our learners know how to learn.

Do they? Do Learners Know How to Learn?

Stated another way, what if after decades of research and millions of hours of instructional design efforts it turns out that the cognitive parts of learning are necessary but insufficient to ensure real learning and eventually real behavior change happens?

To address this question I developed a fairly simple and unassuming research project about 3 years ago – my goal was to better understand what the true “process of learning” really entailed. What I uncovered was what I’ve come to refer to as the Natural Learning Actions.

My research was designed around three questions:

  1. What are the actions that learners physically take as information begins to bubble from sensory to working memory?
  2. How and when are these various actions employed by learners in the process of learning?
  3. As learners explore the actions they take while learning, do they believe that these actions are taken effectively and efficiently?
    In other words: What are the actions? How and when are they employed? And, do they work?

By interviewing over 300 clinician learners and guiding them through a semi-structured exploration of what actions they take while consuming new information, four actions emerged:

As learners consume your educational content they acknowledge to need for 1) taking notes, 2) setting reminders, 3) conducting searches and 4) reacting to external nudges that support and guide their attention.New Learning Actions Graphic

But importantly, how learners leverage these actions is almost completely due to convenience and habit and not trial-and-error; meaning that these actions are often unevolved and therefore the educational planner must accept that without supporting these actions the impact of their interventions is likely to fail to meet their needs.

So what should we each take away from this work? First, is the recognition that simply being smart, does not make one a skilled learner. Each of us must commit to evolving the physical actions we take as we attempt to consume new information and transfer new lessons to positive behavior changes. And second – we can’t assume that just because our learners are some of the smartest folks in the world; that they are adequately equipped to effectively or efficiently learn. It is our job, as educators to create the environment in which the learning actions can be optimized.

The Science of Memory Systems Part 2 – Episode #2

Before we get into today’s topic, let begin with a brief tease…as you listen to episode two keep in mind that in episode three we will focus on a new and emerging instructional design framework called the learning actions model – hopefully you will agree that this is the perfect next building block based on what we’ve covered and in episodes one and two.

In this episode we are digging deeper into the The Science of Memory Systems (PART 2) and we continue to learn lessons from the 2014 publication, “Cognitive Load Theory: Implications for medical education: AMEE Guide No. 86” by Young et al.

Cognitive Load Title Image

Building on what we explored in episode #1 …Here are our Big Three Takeaways:

  1. Everything we do in continuing education is hampered by the bottleneck of working memory
  2. Our job is to mitigate the load we place on learners in an effort to simplify the processing of information
  3. How we define the ‘best educational activities’ we can build based on how effectively we can align intrinsic load of subject matter to learners and how effectively we can eliminate the extraneous load of the learning experience.

As we will do with every podcast, we will start in the author’s words but this time we will jump further into the text and see how they frame the very real and very practical challenge of extraneous load on learning.

Instructional techniques can inadvertently impose extraneous load by, for example, providing insufficient guidance and thereby forcing learners to employ weak problem-solving methods such as trial and error or to search for information needed to complete the task. Similarly, when information necessary for learning is distributed in space (e.g. requiring multiple textbooks or with the physical separation of the written text from the accompanying pictures) or time (e.g. across different lectures), scarce WM resources are used to search for the information and bring it together. A teacher provides visual overload when he shows full text slides but allows too little time for the learners to read them; if, in addition, he gives simultaneous verbal information that does not align with the (visual) slides, distracting (extraneous) cognitive load is introduced that will impair both channels of information. Finally, distractions not related to the task (e.g. the intern’s pager beeping during a lumbar puncture or a colleague interrupting during a handover) impose extraneous load.

Remembering that in episode 1 we focused on the memory systems science from the 50’s and 60’s which defines for us a critical bottleneck in learning.

  1. Infinite sensory memory and infinite long-term memory sandwich a very limited working memory.
  2. Information must be moved from working memory to long-term memory through processing and schema formation
  3. Intrinsic load is relationship b/w content and the learner – too much distance or complexity and model fails.
  4. Extraneous load speaks to the effort required OUTSIDE of the content to support the processing (…this is what we do as educators)

At the risk of over-simplifying the role we each play in mitigating extraneous load, here is how I suggest you think about these lessons.

Every instructional design choice you make in practice will either add to or mitigate extraneous load.

  • Case-based vs didactic?
  • Small group environments vs large plenary sessions?
  • Monotonous speakers vs TED-like polished presentations?
  • Giving handouts or ‘making them available’?
  • Steadfastly meeting power point best practices or simply using whatever the faculty turn in?
  • Stand-alone learning vs serial learning?
  • Opening with a joke, the lighting, the temperature, the seating, the UI of online approaches…

As we progress in this podcast series we will attempt to find the evidence behind each of these decisions and ensure that we are making the right instructional design decision that have been proven to mitigate extraneous load and simplify learning!

In segment 2 of the podcast, we briefly explore some critical productivity best practices for CE professionals. In 2013 I was asked to create a guide that would allow CE professionals to more efficiently stay abreast of critical information and new professional lessons – at the time I called it my “Manifesto for CE Professionals” (you might recognize that this podcast is a perfect example of this Manifesto in action). Here are the basic elements of the manifesto:

  1. Work smarter, not harder
  2. Learn what to learn and when/where to search
  3. “Professionals” share
  4. Sharing is now effortless

The guide is comprised of a video series to provide tutorials on how exactly I ‘work smarter. not harder’ – I strongly advise that you take the time to review the series (complete with my full winter beard) and share the series with you colleagues.

You can find the series here: Use New Technology to Support Your Personal Learning Network

The Science of Memory Systems Part 1 – Episode #1

In this episode we are digging into the The Science of Memory Systems and here are our Big Three Takeaways:

  1. Everything we think about Learning and educational design must be grounded in the science of memory systems
  2. Cognitive load theory provides a critical framework to apply to the science of memory systems to the science of CE
  3. The quickest path to getting a working understanding of cognitive load theory is to begin with the article commissioned by the Association for Medical Education in Europe (AMEE) and written by Young and colleagues entitled, “Cognitive Load Theory: Implications for medical education: AMEE Guide No. 86”


Cognitive Load Title Image

As we will do with every podcast, let’s begin in the authors words with their abstract.

Cognitive Load Theory (CLT) builds upon established models of human memory that include the subsystems of sensory, working and long-term memory. Working memory (WM) can only process a limited number of information elements at any given time. This constraint creates a ‘‘bottleneck’’ for learning. CLT identifies three types of cognitive load that impact WM: intrinsic load (associated with performing essential aspects of the task), extraneous load (associated with non-essential aspects of the task) and germane load (associated with the deliberate use of cognitive strategies that facilitate learning). When the cognitive load associated with a task exceeds the learner’s WM capacity, performance and learning is impaired. To facilitate learning, CLT researchers have developed instructional techniques that decrease extraneous load (e.g. worked examples), titrate intrinsic load to the developmental stage of the learner (e.g. simplify task without decontextualizing) and ensure that unused WM capacity is dedicated to germane load, i.e. cognitive learning strategies. A number of instructional techniques have been empirically tested. As learners’ progress, curricula must also attend to the expertise-reversal effect. Instructional techniques that facilitate learning among early learners may not help and may even interfere with learning among more advanced learners. CLT has particular relevance to medical education because many of the professional activities to be learned require the simultaneous integration of multiple and varied sets of knowledge, skills and behaviors at a specific time and place. These activities possess high ‘‘element interactivity’’ and therefore impose a cognitive load that may surpass the WM capacity of the learner. Applications to various medical education settings (classroom, workplace and self-directed learning) are explored.

I find that the figure below, from AMEE Guide No. 86 does a great job at simplifying this:

Memory Systems Image from AMEE86


To provide a bit more detail – CLT identifies three types of cognitive load:

  1. Intrinsic load—load associated with the task. Intrinsic load generated by a task cannot be altered by instructional interventions without either simplifying the task to be learned or first enhancing the expertise of the learners by providing preparatory training prior to the task.
  2. Extraneous load—load not essential to the task. Instructional techniques can inadvertently impose extraneous load by, for example, providing insufficient guidance and thereby forcing learners to employ weak problem-solving methods such as trial and error or to search for information needed to complete the task. Similarly, when information necessary for learning is distributed in space (e.g. requiring multiple textbooks or with the physical separation of the written text from the accompanying pictures) or time (e.g. across different lectures), scarce WM resources are used to search for the information and bring it together.
  3. Germane load—load imposed by the learner’s deliberate use of cognitive strategies to reorganize information to make it suitable for storage in LTM, i.e. to learn. There is some debate as to whether germane load constitutes its own category or is best understood as a constituent of intrinsic load. Germane load can be viewed as the learner’s level of concentration devoted to learning (as opposed to performing the task). Germane load is regulated by the individual. When the extraneous and/or intrinsic load are too high and approach or exceed the learner’s WM limits, there will be insufficient WM resources available for the germane load necessary for learning

Within the podcast we spend a fair amount of time explaining why we need to focus our energies on mitigating extraneous load. And, we will dedicate our time in Episode 2 focusing on specific opportunities we have to do this!