Asynchronous Learning: Getting Your 5 th Hour in Sync

1. Asynchronous Learning:Getting Your 5th Hour in Sync Moderator: Linda Regan, MD Panel: Samuel Luber, MD and Michael Wainscott, MD Douglas Char, MD Autumn Graham, MD David Overton, MD and William Fales, MD Matthew Waxman, MD and Tess Klaristenfeld, MD

2. RRC Guidelines • Planned Educational Experiences for Residents • 20% can be Individualized Interactive Instruction • Four Criteria must be met: • The program director must monitor all activities for resident participation • There must be faculty supervision • There must be an evaluation component • The activity must be monitored for effectiveness

3. Asynchronous in Texas • Dr. Michael Wainscott • Dr. Samuel Luber

4. UT Southwestern and UT-Houston • Why we are presenting together • The “Menu” Approach • Asynchronous Offerings • Logging Asynchronous Learning • Monitoring Asynchronous Learning

5. Lectures

6. Hands-On

7. Courses

8. Meetings/Courses

9. Online

10. Other

11. Logging • UT Southwestern • Residents log their Asynchronous Learning time as a procedure in the residency management suite • UT Houston • Began program logging on paper • Transitioned to online log with “evaluation component” • Using GoogleDocs, data automatically entered into spreadsheet for review

13. Monitoring • UT Southwestern • Log reviewed at Mid-year/End-of-year evaluation with other procedures • UT Houston • Log reviewed at quarterly mentor meetings • Resident will not be promoted if total hours not completed by end-of-year

14. Compliant with RRC-EM?

15. Questions?

16. Asynchronous Education: Fad or Paradigm shift? Douglas M. Char, MD CORD Academic Assembly 2011

17. Asynchronous Didactic Balance Pros Cons Difficult to ensure consistent curriculum and educational experience Cost Need to ensure material remains “current/updated” and available (circulation) Less time to cover other portions of the curriculum Resident may gravitate to strengths and avoid areas of weakness under guise of “individualization” • Allows residents to maintain “conf” credit when sick, on vacation, post call, off-service • Reinforces self-directed education • Match didactic emphasis with clinical rotation • Use outside resources to strengthen curricular deficits • Customized curriculum meets individual interests • Better attention during conference (less hours sitting)

18. Logistical considerations • Once you start reducing “lecture/group” time hard to reverse the trend • Determining what part of curriculum appropriate for asynchronous approach • What do we do well (don’t “fix it”) • Identifying appropriate material • Initial set up to allow accurate tracking of individual effort • Completed in timely manner • Evidence of competence assessment (understanding) • Faculty time and effort initiating and maintaining asynchronous didactics • Decreased conference scheduling flexibility

19. What was already in place • Existing rotation specific educational effort • ENT – COOL modules (Am Acad ENT Head & Neck Surg) • Patient Sat/Risk management – ED/X (ECI) • Procedural sedation – education/credentialing modules (BJH/SLCH) • NIHSS training (shared with neuro) • Residents already expected to do this as part of a rotation (in place of assigned readings) • Evaluation (test) incorporated into module • If we assign this as “asynch didactic” we have reduced opportunity to expose trainee to other material • “Can’t keep adding more requirements – no time” • Accused of being paternalistic “PD knows what’s best”

20. What we did • PDs and Chief Residents identified areas of strength and weakness within our existing didactic curriculum • Goal was to address perceived weaknesses • Work group researched possible resources • Assign web accessible modules - commercially available sites • Emedhome.com • Cmedownload.com • Paid for access for all residents and faculty (2 hours/mo 2009) • Limited access to residents/select faculty (4 hours/mo 2010) • Assignment listed on the monthly conference schedule • Proof of completion must have time stamp • No retroactive credit initially (now allowing make up) • Resident responsible to providing program secretary “proof” No commercial interest in products selected

21. Sample Asynchronous Assignments

22. How it’s going • Residents enthusiastic in the beginning • Some now see this as one more hoop – don’t appreciate that it’s less confernece time (they never experienced that) • Those who have a hard time making conf – have a hard time completing online assignments • Material assigned last year may no longer be available online as the site makes revisions, updates • Not all material within a site of the same caliber and value • If we assign this year will it be available 2 years from now • Cost $$$ ($200/resident per year) • Little faculty involvement in this – they don’t know what residents do regarding these topics • Coordinating faculty spending more time searching for “good stuff” than anticipated • How do I know this is better than the old way?

23. Where we hope to go • Need to get away from one size fit’s all • Everyone doing the same online modules every month • How to individualize without tracking nightmare • Pull material from specific rotation reassign as asynchronous education • Activity will be specific for a given rotation • Be aware of adding to the curriculum without measuring it’s impact on compliance, “learning” • Start to develop “Scholar Track” specific activities for upper level trainees (GPY 3-4) • This will allow more individualization of curriculum and match interest with effort • Requires program better define core curriculum • This can’t be a fad, need to consider long-term impact • Faculty time, teaching expectations

24. Questions?

26. Landscape • 3 year program with multiple training sites • 8 residents per year • 48 conference days a year • 4 hours of weekly conference • 1 hour of asynchronous learning

27. Guided “Choose Your Own Adventure”

28. Board Review Components Evaluation Semi annual examination Review of in-service examination • Choose from a number of sources • PEER series • CORD Question Bank • AAEM: A Focused Review of the Core Curriculum Questions • 1000 Questions to help you pass the emergency medicine boards • Emergency Medicine: Examination and Board Review

29. EMRAP Podcast Component Evaluation CME questions: Pretest/Post-test Best of EM:RAP • Resident choice of monthly podcast session

30. Senior Directed Curriculum Components Evaluation Mentored program with attending physician panel Small group format • Career Development Skills • Time table • CV preparation • Networking • Interview skills • Job selection • Pitfalls from Alumni • Contract evaluation • Negotiation

31. Skill Labs Component Evaluation Precepted activity Pretest/Post-test Audience response system • ENT • Epistaxis Management • Nasopharyngeal Scope • Ophthalmology • Slit Lamp Examination • Visual Diagnosis Rapid Fire • Orthopedics • Rapid Ortho Imaging and Management • Splinting Lab • Dislocation/Reduction Techniques

32. Simulation Component Evaluation Individually precepted activity Interactive Pretest/ Post-test • Customized individual simulation session focusing on resident and residency assessed need

33. SiTEL Component Evaluation Interactive Pretest/Post - test • Pre-approved on-line modules • Adult Procedural sedation • Pediatric Procedural sedation • Trauma Triage • SBAR Communication • NIH Stroke Management

34. Education Component Evaluation Goals and objectives Lecture Summary of audience evaluation Oversight by physician director of program • Lecture development for multi-level audiences • Medical students • Nurses • Undergraduate students • EMS/Fire

35. Ultrasound/Review Component Evaluation Precepted Activities Interactive • Hands on practical application • Weekly ultrasound review • Indication for ultrasound • Pertinent medical/clinical considerations • Quality of images • Suggestions for improvement

36. Approved Asynchronous Learning Component Evaluation Varies depending on activity • National Conference • Pediatric Anesthesia/Sedation • Oral surgery clinic

37. Asynchronous Learning Monitoring and Oversight • Residents • Log activities on a Googledoc spreadsheet monthly • Review approved activities/preceptor quarterly via survey monkey and P&C Committee • Residency • Approves activities that meet RRC requirements and have a proven educational benefit • Reviews the log quarterly • Reviews the log in semi-annual evaluations and sets future educational goals

38. Questions?

39. Simulation WednesdaysAn Experiment in Asymmetric Learning William Fales, MD Associate Professor of Emergency Medicine David Overton MD, MBA Professor of Emergency Medicine Michigan State University Kalamazoo Center for Medical Studies

40. History / Background • EM Program: 1-3 format with 20 residents/year • Traditional 5-hour weekly didactic conferences • Institutional Simulation Center x 10 years • Administered by Emergency Medicine • Modest in size (2,250 square feet) • 1-bed “Trauma/ICU Room” + 4-bed “ED Ward” • Central control room with AV system monitors • Multi-purpose Bioskills Lab / Classroom • Two, 20-foot , single bed mobile labs • Historically light on simulation

41. The Challenge: • Residents and faculty viewed simulation as: • Educationally valuable • Underutilized • The Challenge: • How to expand use of simulation • While preserving core didactic instruction

42. The Solution – “Sim Wednesdays” • Dedicate one entire Wednesday per month, replacing one EM conference day • Typically offered the last Wednesday of the month • Prep residents for coming off-service rotations • Interdisciplinary • >90% EM residents • Instructors • EM Faculty and PGY-3 Residents • Supported by Simulation and EMS staff

43. Resident Assignments

44. Example: Critical Care Sims • 1 ¼ hours of basic skill practice • Airway, central lines, ventilator management • STICU also does FAST review • 2¾ hours of team-based simulations • Standardized case scenarios (~15 min each) • Essential and desired intervention defined • 1:1 simulation/debrief ratio • Focus on critical decision-making, teamwork, safety • Residents play role of nurses, RT, etc. • Keeps everyone engaged

45. Example: OB (Noelle) • 1-2 residents per month • Beforehand: complete online readings, view lecture and complete multiple choice exam (via Moodle) • Independent, but verifiable • Sim Wed: perform multiple deliveries with Noelle: • Normal, breech, nuchal cord, prolapsed cord, shoulder dystocia • Check-listed and competency-assessed

46. Advantages, Disadvantages & Considerations • We have a large residency (20 residents/year) • Thus, we need a large Simulation Lab • To fit all the people • To have the capability to run enough stations simultaneously • Keep everyone busy without making the groups too large

47. Advantages • Residents love it • It’s hands-on • It’s action-orientedation • “Just-in-time” education • Good politically • You can build bridges with other programs • Other program residents can attend • Other program faculty can teach • You look good • “Hands across the water”

48. Faculty Considerations • Advantages - They like it, too • Takes little to no faculty prep time, unlike a traditional lecture • After they learn the station, they just show up and do it • Faculty get much more one-on-one contact with residents than with a traditional lecture • Disadvantages - It takes a lot of faculty to run • Faculty have to consistently attend each month • Faculty may even get bored and want to change stations

49. Additional Considerations • Conference Time • This takes up ~25% of conference time • Thus, the rest of the curriculum is compressed by 25% • Thus, less time to fit in other conferences • Thus, less time to fit in resident lectures • Competencies • Very convenient place to accomplished RRC-required competency assessments: • “…one type of resuscitation” • “…three procedures”

50. Questions?