Nadim Lalani MD Online Education in the ER
Vanilla Sky • Tom Cruise 2001 • Existential “Mind warp” • Deals with cryogenics and the possibility of living a virtual life after death • Blending of the technologic and biologic worlds “plugged in’ • ?Virtual [technologic] world to supplement [real world] EM medical education
Objectives • Definition • Background • Literature Review • Med Ed • Resident Ed • Professional Development • What it might look like • Future Directions
What is “Online learning”? • Online Learning [e-learning] = is digital • Evolved from CD/computer labs • Everyone does it! • Performance Support [ for software e.g] • Web page [e.g. Uptodate] • Self-paced Web-based [CME] • Leader-led [ Distance Learning] • Blended [or hybrid] learning • combines conventional with digital learning
Advantages of e-learning • Rich environment: • Media-filled [esp in EM] • transfer of difficult concepts • Links to sources • Convenient, efficient & flexible • Asynchronous • Can be accessed from a distance • Adult learning principles: • Self-paced and self-directed • Flexible/ home access • efficiency
Background: Why bother? • U of C Medical School current enrollment = 130 students goal 150 • Mandatory EM rotation / increasing competencies • Resident numbers also increasing • Result more learners in the ED • Relative shortage of preceptors, relevant clinical encounters and curricular time • Will be worse when our program expands usurp learning opportunities
Why bother • Deficiency in learning encounters = a performance gap • future physicians do not have the adequate exposure to emergent problems. • imperative we equip students, clerks & residents with the skills and training.
why bother • Increased digitalisation is a key strategic goal of the U of C • Learners are unique with mulitdimensional learning styles. • Adult learning principles • Attract the best candidates • Provide a method of training students and clerks at two different campuses • Provide consistency in teaching
Why bother? • Provide efficient means of knowledge transfer toresidents • Increasing number of competencies [CANMEDs] • Better use of academic half-day. • Provide more effective professional development: • Asynchronous don’t have to be there • Interactive discussion board • Consistent, evidence-based standard of practice • Increased self-efficacy
E-learning not a panacea • there is more to training and education than e-learning • Certain skills do not lend themselves to e-learning • The key will be selecting the best delivery method. • Cannot simply upload old material. • Learner – focused • no one solution [blended may work for residents].
Process: Can it be done? “Fail to prepare … prepare to fail” • Need to address several key questions: • Purpose? Added value? • What support and expertise exist? • Ongoing upkeep? • Stakeholders? • Team? • Instructional design/Pedagogy
Literature Review • Same Search terms in PUBMED • Bibliographies of relevant articles scanned • Missing 1 Med Ed & 1 CME [both foreign language]
Literature general Comments • More Literature exists for Med Ed • Pre 1990 Limited by lack of internal validity • Few Randomised Controlled Studies • Emerging Lit wrt Resident experience • Despite lots of experience with online CME • Little Literature … mostly Descriptive
Literature General Comments • Terminology inconsistent • Interventions vary. • ? “prototypes” of today’s technology? • Don’t address some of the uniqueness [internet] • Comparing apples to oranges
E Learning & Med Ed Can E-learning be used to replace/augment Traditional Methods?
Study Dartmouth Med School • 328 Students randomised to: • Interactive Case-based study guide on Computer* • Case-Based Printed study guide • Anemia and Cardiology Courses • Outcomes: • Performance on higher order MCQ tests, exams • Self-reported Efficiency * media-rich images, blood smears and EKG’s
Results • No Difference in Test Scores • No difference on board exams • The vehicle is an acceptable means of delivery
Limitations • Self reporting of efficiency! • Confounders [other text books/practice exams/time-spent cramming] • Doesn’t really tell us about dynamic problem-solving/ clinical judgment
179 Paeds Clerks in [2 sites Chicago] • Randomised to Lecture via: • Multimedia Text Book* • Lecture • Printed Text • No intervention • Paeds airway diseases • Outomes: • MCQ Test Score [at end of rotation & at 1 y later] * Only different in audio/video
Limitations • 51% Attrition rate! • Clerks at one site had mail-in repeat exam • Confounders • One hour instruction embedded in a 6 week clerkship
75 Med students [Brisbane Australia] • Randomised after pretest to: • Computer Tutorial Focus on knowledge • Computer tutorial create ideal patient for dx + feedback [every 10 cases] • Computer Tutorial both knowledge & decision + three different types of feedback [after every 10 cases] • Looking at diagnosing abdo pain [ 30 cases]
Outcomes and Results • Outcomes: • Attained knowledge • Diagnostic accuracy • Decision-making confidence [self reported] • Results: • Students focusing on facts did not improve decision-making • All feedback groups improved diagnostic accuracy • Type of Feedback not important. • Self reported confidence improved
Limitations • Small study • Very convoluted method ?reliability
E- Learning & Med Ed Can E-learning be used to Teach Procedural Skills?
82 Medical Students [Toronto & Augusta] • Randomised to: • Computer Tutorial + knot board • Lecture with Feedback + knot board • Two-Handed Knot tying • Tested right after [filmed] • Outcomes: • Proportion Square/ Time to tie • Knot Performance score [blinded surgeons] • Student Questionnaire
Results • NO difference in “Cognitive” portion • Lower performance score in CAL group • 89% Students would have preferred Lecture Session • Lack of feedback cited as negative
Limitations • Apples and Oranges! • ? Not controlled for hands-on feedback • Maybe CAL better if it described pitfalls / showed video of good and bad knots? • Reliability of performance score [not included]
42 Clerks U of T • Randomised to: • Computer Tutorial [rich text, animations, interactive –Q&A, no audio/video] • small group seminar [also interactive] • Epistaxis Management • Outcomes: • Short Answer written Test • Practical Test [16 point performance scale]
Results: • Poor Prior knowledge • No difference in written scores • Slightly better practical skills with CBL
Limitations: • Small numbers • Examiners NOT blinded • ?reliability of performance score [not included] • Practical was on dummy • ? transferability
69 Medical Students [Wisconsin] • After pre-test Randomised to: • Didactic Session/Q&A¥ • Video-Tape Session* • Computer Tutorial* • Post Intervention: • MCQ test, Practical Skills test [2 blinded obs] • Repeat testing at one month ¥ no feedback . * Instructor present
Outcomes: • MCQ Test Scores • Timed observation of skills • Critical Skills evaluated via checklist • Performance Quotient calculated
Results • Higher initial mean % correct / % complete in CBT group [p<0.01] • Significantly better PQ in CBT group at 1 month [p < 0.01]
Results • Didactic group better on immediate MCQ [63% vs 49% for video/CBT p < 0.01] • Difference in MCQ still there at 1 month
Results • Bigger change in PQ with CBT at 1 month [ P< 0.01]
Limitations • Small study • Video vs CBT essentially the same intervention • ? Why CBT would do better than Video • ? Reliability of checklist and PQ?
What About the ED Experience? Can E-Learning be used for Emergency Medicine Rotations?
100 Clerks [Mt Sinai] Randomised by blocks • EM rotation with access to EM Website • Modules [ACLS, Tox], Xrays, Pix, Paeds Cases • EM Rotation without access • Outomes: • Exam Scores • Student Satisfaction
Results • ONLY 28% intervention group used it. • 72% Cited lack of time • NON sig difference in exam score [72.8 vs 68.2 p = 0.058] • Non sig difference in satisfaction [ 77.5% vs 66% p = 0.23] • Baseline only 26% > 1h /wk online [cf 96% next class] • Baseline 65% wanted online component
Limitations • < 30% in intervention group didn’t reach power. • WAS ITT so results would have been +ve with more participants • Problems with randomising by block rotations given away on lottery [ CARMs] • Unmotivated learners? • ?generalisable to clerks in 2008
23 Clerks [U of T Sick Kids] • Volunteered for study, Randomised to • Access to Web-based Modules • No Access to Web-based modules • ED Procedures [lac, LP, splint] • Outcome: • Performance on MCQ Test
Results • Statistically higher competence [ p = 0.0001] • Cohen’s d Effect size r = 0.79
Limitations • Small sample size • Volunteers [EM /techno gung-ho] • Methodology: • Unclear when test was administered in relation to rotation • ?randomised to learning vs no learning? • Validity of MCQ vs Observed skills • Transfer of knowledge? • MCQ vs Observed skills
350 Urology Clerks [4 med schools US] • Randomised [two-group crossover] to: • Web-based Tutorials [BPH,ED,PC,PSA] • No Access to Web Tutorials • Served as the controls for the modules they didn’t have access to online • Outcomes: • Performance on test [pre/post] [Cr = .79] • Durability of learning/ Learning efficiency in SubG
Results • Learning Efficiency 0.10 vs 0.03 [p<0.001] • Test scores still improved without WBT [12% BPH, 6% ED, 24% PC, 20% PSA] • Web-based alone had Cohen’s r = 24.9!
Limitations: • Volunteers with unequal participation b/w sites [93% HMS vs 52% BUSM] • High Drop out rate 210 /350 completed • ? Generalisability of repeated measures • ? Generalisability to EM