Asynchronous Learning: Getting Your 5th Hour in Sync

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Asynchronous LearningGetting 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

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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

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Asynchronous in Texas

• Dr. Michael Wainscott
• Dr. Samuel Luber

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UT Southwestern and UT-Houston

• Why we are presenting together
• The Menu Approach
• Asynchronous Offerings
• Logging Asynchronous Learning
• Monitoring Asynchronous Learning

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Lectures
UTSW UT-Houston
Total Async Hours Required 42 hours/year 45 hours/year

Outside Regular Conference Lecture-Based Outside Regular Conference Lecture-Based Outside Regular Conference Lecture-Based
Intern Conference 2 hours/month 2 hours/month
Toxicology Grand Rounds 1 hour/month -
Trauma Conference 2 hours (during rotation) -
EMS Base Station Course 8 hours 4 hours
Resident in Charge Mtg 2 hours -
Resident Transition Mtgs 2 hours -
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Hands-On
UTSW UT-Houston
Monthly Skills/Sim Lab - 1-2 hours
EM2 Skills Lab - 6 hours
Ultrasound Shifts 1-2 hours/shift 1-2 hours/shift
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Courses
UTSW UT-Houston
ACLS 8 hours 8 hours
ATLS 8 hours 8 hours
PALS 8 hours 8 hours
Neontal Resus Course 8 hours 8 hours
Recertification for above 4 hours 4 hours
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Meetings/Courses
UTSW UT-Houston
ACEP Scientific Assembly 3 hours/day (12) 3 hours/day (12)
TCEP Annual Meeting 2 hours/day (8) 2 hours/day (8)
SAEM Annual Meeting 3 hours/day (12) 3 hours/day (12)

Business of EM Course 12 hour course 1 hour/meeting
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Online
UTSW UT-Houston
MedScape CME - ¼ hour/module (20 hrs)
ACEPs FocusOn - ½ hour/module (5 hrs)
Sullivan Group CME - 1 hour/module (4 hrs)
Q.A. Newsletter/Quiz - ½ hour/module (6 hours)
UT Risk Management - 4 hours
Human Subjects Protection Training 4 hours
NIH Stroke Scale Certification - 2 hours
S.A.F.E.R. Training - 2 hours
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Other
UTSW UT-Houston
Scholarly Project 4 hours -
Performance Improvement Project 2 hours -
Journal Club 2 hours/journal club -
Resident as Teacher Seminars 1 hour -
Chart Review 1 hour -
Monthly Board Review 2 hours/month -
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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

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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

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Compliant with RRC-EM?
UTSW UT-Houston
The program director must monitor all activities for resident participation
There must an evaluation component
There must be faculty supervision
The activity must be monitored for effectiveness
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Questions?
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Asynchronous Education Fad or Paradigm
shift?

• Douglas M. Char, MD
• CORD Academic Assembly 2011

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Asynchronous Didactic Balance

• Cons

• Pros

• 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)

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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 (dont 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

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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
• Cant keep adding more requirements no time
• Accused of being paternalistic PD knows whats
  best

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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
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Sample Asynchronous Assignments
October 2010 How the experts thinkCardiology, Emedhome How the experts thinkTrauma, Emedhome Ten Ways to Lose and Airway, CME download Critical Cardiology in the Emergency Department , CMEdownload Mattu 1hr Betzner and Plant 1h Peter DeBlieux 1 hr Jorge Martinez 1 hr
November Are c-spine plain XR obsolete?   Emedhome   Do patients pith themselves? Emedhome  Tox Myths and pseudomyths Emedhome When the ticker starts to flicker Emedhome ALTE Simplified CMEdownlaod Life Threatening Rashes CMEdownload Mistakes to Avoid in Kids CMEdownload Quickie Snappies Day 1 CMEdownload Bart Besinger    .5hr Geoff Hayden .5hr Andrew Stolbach .5hr Kevin Reed .5hr 30 min 35 min 38 min 26 min
December Rads in Pregnancy Emedhome Review of new AHA guidelines EMCast Five articles that may change your practice. Emedhome peds head injury, peds status, some airway, ?etomidate in sepsis A skeptics guide to reading the medical literature, part 2 Jeff Ufberg .5 hrs. Amal Mattu 1.5 hrs Kevin Curtis, .75hr Joe Lex, 1hr
January, 2011 Drugs and Devices 2009 That Might Change Your Pratice (1)AHA Guidelines Dysrhythmias (2) Aortic Dissection (3) Lower GI Bleeding (4) Pulmonary Embolism Stroke http//learn.heart.org/ihtml/application/student/interface.heart2/nihss.html Joe Lex 1 hr. Amal Mattu 1.5 hr On line certificate
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How its going

• Residents enthusiastic in the beginning
• Some now see this as one more hoop dont
  appreciate that its 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 dont
  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?

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Where we hope to go

• Need to get away from one size fits 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 its 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 cant be a fad, need to consider long-term
  impact
• Faculty time, teaching expectations

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Questions?
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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

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Guided Choose Your Own Adventure
Activity Credit
Mandatory Board Review 1 hr per 60 questions
EMRAP 2 hr per monthly session
Senior Directed Curriculum/ Career Workshop 1 hr per session
Skill Lab 1 hr per session
Simulation 1 hr per session
SiTel 1 hr per module
Education 1 hr per lecture
Ultrasound 1 hr per session
National Conferences SAEM/ACEP/AAEM 4 hr per conference
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Board Review

• Components

• Evaluation

• 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

• Semi annual examination
• Review of in-service examination

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EMRAP Podcast

• Component

• Evaluation

• Resident choice of monthly podcast session

• CME questions
• Pretest/Post-test
• Best of EMRAP

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Senior Directed Curriculum

• Components

• Evaluation

• Career Development Skills
• Time table
• CV preparation
• Networking
• Interview skills
• Job selection
• Pitfalls from Alumni
• Contract evaluation
• Negotiation

• Mentored program with attending physician panel
• Small group format

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Skill Labs

• Component

• Evaluation

• ENT
• Epistaxis Management
• Nasopharyngeal Scope
• Ophthalmology
• Slit Lamp Examination
• Visual Diagnosis Rapid Fire
• Orthopedics
• Rapid Ortho Imaging and Management
• Splinting Lab
• Dislocation/Reduction Techniques

• Precepted activity
• Pretest/Post-test
• Audience response system

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Simulation

• Component

• Evaluation

• Customized individual simulation session focusing
  on resident and residency assessed need

• Individually precepted activity
• Interactive
• Pretest/ Post-test

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SiTEL

• Component

• Evaluation

• Pre-approved on-line modules
• Adult Procedural sedation
• Pediatric Procedural sedation
• Trauma Triage
• SBAR Communication
• NIH Stroke Management

• Interactive
• Pretest/Post - test

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Education

• Component

• Evaluation

• Lecture development for multi-level audiences
• Medical students
• Nurses
• Undergraduate students
• EMS/Fire

• Goals and objectives
• Lecture
• Summary of audience evaluation
• Oversight by physician director of program

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Ultrasound/Review

• Component

• Evaluation

• Hands on practical application
• Weekly ultrasound review
• Indication for ultrasound
• Pertinent medical/clinical considerations
• Quality of images
• Suggestions for improvement

• Precepted Activities
• Interactive

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Approved Asynchronous Learning

• Component

• Evaluation

• National Conference
• Pediatric Anesthesia/Sedation
• Oral surgery clinic

• Varies depending on activity

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Asynchronous Learning Monitoring and Oversight

• Residents
• Log activities on a Googledoc spreadsheet monthly
• Review approved activities/preceptor quarterly
  via survey monkey and PC 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

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Questions?
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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

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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

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The Challenge

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

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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
• gt90 EM residents
• Instructors
• EM Faculty and PGY-3 Residents
• Supported by Simulation and EMS staff

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Resident Assignments
PGY-1 PGY-2 PGY-3
Medical ICU 2 1 2
Pediatric ICU 2 1 2
Surgical /Trauma ICU 2 1 2
Ultrasound 2 2
OB - 1 -
Animal Lab 1 1 2
Independent Study (ABLS, EMS, Disaster) 1 3 -
Float Instructor - - 2
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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
• 11 simulation/debrief ratio
• Focus on critical decision-making, teamwork,
  safety
• Residents play role of nurses, RT, etc.
• Keeps everyone engaged

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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

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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

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Advantages

• Residents love it
• Its hands-on
• Its 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

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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

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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

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Questions?
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Results of 2010 Asynchronous Learning SurveyCORD
Scientific Assembly 2011San Diego, CA

• Matthew Waxman, MD
• Tess Klaristenfeld, MD, MPH
• Scott Votey, MD
• UCLA/Olive View-UCLA Emergency Medicine Residency
  Program

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Background

• research is needed to clearly define those
  educational activities that benefit from one type
  of of learning over another Conference
  Attendance Work Group 2008 CORD Scientific
  Assembly
• What is the state of affairs (2010) for
  Asynchronous Learning(AL) in EM?
• What are programs out there actually doing with
  AL?
• What are the sources of content being used in AL?
• Is Asynchronous Learning Meeting the Educational
  Goals of our Residents?

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Methods

• Survey Monkey online survey
• Recruitment of participants from CORD Listserve
• 6 weeks duration, two e-mailed pleas for
  compliance
• SurveyMonkey calculated percentages of responses
• 85 responses in a 6 week period

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Are EM Programs Doing AL?What content sources
are they using??
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Other Sources of AL Material Reported by
Respondents

• Video recordings of educational sessions
• Simulation
• Graduate degree coursework
• Attending lectures in outside departments
• Faculty Supervised Small Group Sessions

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Why Programs are not using AL?
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Other Reasons by Respondents for not Using AL

• Uncertainty of RRC/ACGME regulations
• Perception of Cost
• Technical issues in developing or maintaining
  sites for AL
• Have not drunk the CoolAid

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How Much Time Devoted to AL?(hours per year)
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Use of AL in Fulfilling Program Requirements

• (48/85) 56 respondents stated they are using AL
  for conference credit
• Variation between
• Optional vs. Mandatory
• Mechanism for Remediation
• Unsatisfactory Conference Attendance

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Other Results

• 92 of respondents interested in participating in
  online clearinghouse of asynchronous resources
• 27 respondents (30) are measuring resident
  learner satisfaction with AL
• Measured in written evaluations of AL activities
• Retreat feedback
• Evaluations with PDs

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Limitation of Survey and Future Direction

• Multiple PDs from each program may have responded
• Did not survey each program
• How should be measure success of AL
• Is AL really an educational activity or is it
  getting residents out of conference?
• Standardizing an EM Curriculum divided up amongst
  participating programs
• Incorporation into ACGME language of milestones
  in training

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Our Favorite Asynchronous Sites

• Gorgas School of Tropical Medicine Clinical Cases
  http//gorgas.dom.uab.edu/
• Feinberg School of Medicine EM Radiology Teaching
  http//www.feinberg.northwestern.edu/emergencymed/
  residency/ortho-teaching/index.html
• UCSD Toxicology Teaching Modules