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
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
Asynchronous in Texas
• Dr. Michael Wainscott
• Dr. Samuel Luber
UT Southwestern and UT-Houston
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Why we are presenting together
The “Menu” Approach
Asynchronous Offerings
Logging Asynchronous Learning
Monitoring Asynchronous Learning
UTSW
Total Async Hours
Required
Lectures
42 hours/year
UT-Houston
45 hours/year
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
-
Hands-On
UTSW
UT-Houston
Monthly Skills/Sim Lab
-
1-2 hours
EM2 Skills Lab
-
6 hours
1-2 hours/shift
1-2 hours/shift
Ultrasound Shifts
Courses
UTSW
UT-Houston
ACLS
8 hours
8 hours
ATLS
8 hours
8 hours
PALS
8 hours
8 hours
Neontal Resus
Course
Recertification
for above
8 hours
8 hours
4 hours
4 hours
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)
12 hour course
1 hour/meeting
Business of EM
Course
Online
MedScape CME
ACEP’s FocusOn
Sullivan Group CME
Q.A. Newsletter/Quiz
UT Risk Management
Human Subjects Protection
Training
NIH Stroke Scale Certification
S.A.F.E.R. Training
UTSW
UT-Houston
-
¼ hour/module (20 hrs)
-
½ hour/module (5 hrs)
-
1 hour/module (4 hrs)
-
½ hour/module (6 hours)
-
4 hours
4 hours
-
2 hours
-
2 hours
Other
UTSW
UT-Houston
Scholarly Project
4 hours
-
Performance
Improvement Project
2 hours
-
2 hours/journal club
-
Resident as Teacher
Seminars
1 hour
-
Chart Review
1 hour
-
2 hours/month
-
Journal Club
Monthly Board Review
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
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
Compliant with RRC-EM?
UTSW
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
UT-Houston
Questions?
Asynchronous Education:
Fad or Paradigm shift?
Douglas M. Char, MD
CORD Academic Assembly 2011
Asynchronous Didactic Balance
Pros
• 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)
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”
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
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”
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
No commercial interest in products selected
– 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”
Sample Asynchronous Assignments
October 2010 How the experts think—Cardiology,
How the experts think—Trauma,
Ten Ways to Lose and Airway,
Critical Cardiology in the Emergency Department ,
Emedhome
Emedhome
CME download
CMEdownload
Mattu 1hr
Betzner and Plant 1h
Peter DeBlieux 1 hr
Jorge Martinez 1 hr
November
Are c-spine plain XR obsolete?
Do patients pith themselves?
Tox Myths and pseudomyths
When the ticker starts to flicker
ALTE Simplified
Life Threatening Rashes
Mistakes to Avoid in Kids
Quickie Snappies Day 1
Emedhome
Emedhome
Emedhome
Emedhome
CMEdownlaod
CMEdownload
CMEdownload
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
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
Jeff Ufberg .5 hrs.
Amal Mattu 1.5 hrs
Kevin Curtis, .75hr
Joe Lex, 1hr
Joe Lex 1 hr.
Amal Mattu 1.5 hr
On line certificate
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?
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
Questions?
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
Guided “Choose Your Own Adventure”
Activity
Credit
Mandatory Board Review
1 hr per 60 questions
EMRAP
2 hr per monthly session
Senior Directed Curriculum/
Workshop
Career
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
Board Review
Components
Evaluation
 Choose from a number of
sources
• Semi annual examination
• Review of in-service
examination
 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
EMRAP Podcast
Component
Evaluation
• Resident choice of
monthly podcast session
• CME questions:
– Pretest/Post-test
• Best of EM:RAP
Senior Directed Curriculum
Components
Evaluation
• Career Development Skills
• Mentored program with
attending physician panel
• Small group format
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–
–
–
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–
–
Time table
CV preparation
Networking
Interview skills
Job selection
Pitfalls from Alumni
Contract evaluation
Negotiation
Skill Labs
Component
Evaluation
 ENT
• Precepted activity
• Pretest/Post-test
• Audience response system
 Epistaxis Management
 Nasopharyngeal Scope
 Ophthalmology
 Slit Lamp Examination
 Visual Diagnosis Rapid Fire
 Orthopedics
 Rapid Ortho Imaging and
Management
 Splinting Lab
 Dislocation/Reduction
Techniques
Simulation
Component
Evaluation
• Customized individual
simulation session
focusing on resident and
residency assessed need
• Individually precepted
activity
• Interactive
• Pretest/ Post-test
Component
Evaluation
• Pre-approved on-line
modules
• Interactive
• Pretest/Post - test
– Adult Procedural sedation
– Pediatric Procedural
sedation
– Trauma Triage
– SBAR Communication
– NIH Stroke Management
Education
Component
Evaluation
• Lecture development for
multi-level audiences
• Goals and objectives
• Lecture
• Summary of audience
evaluation
• Oversight by physician
director of program
–
–
–
–
Medical students
Nurses
Undergraduate students
EMS/Fire
Ultrasound/Review
Component
Evaluation
• Hands on practical
application
• Weekly ultrasound review
• Precepted Activities
• Interactive
– Indication for ultrasound
– Pertinent medical/clinical
considerations
– Quality of images
– Suggestions for
improvement
Approved Asynchronous Learning
Component
Evaluation
• National Conference
• Pediatric
Anesthesia/Sedation
• Oral surgery clinic
• Varies depending on
activity
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
Questions?
Simulation Wednesdays
An 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
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
The Challenge:
• Residents and faculty viewed simulation as:
– Educationally valuable
– Underutilized
• The Challenge:
– How to expand use of simulation
– While preserving core didactic instruction
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
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
1
3
-
-
-
2
(ABLS, EMS, Disaster)
Float Instructor
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
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
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
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”
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
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”
Questions?
Results of 2010 Asynchronous
Learning Survey
CORD Scientific Assembly 2011
San Diego, CA
Matthew Waxman, MD
Tess Klaristenfeld, MD, MPH
Scott Votey, MD
UCLA/Olive View-UCLA Emergency Medicine Residency Program
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?
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
•
•
Are EM Programs Doing AL?
What content sources are they using??
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
Why Programs are not using AL?
Low
Administrative
Expected Resident
Time
Unreliable
Other,
, 0Sources,
0 00 0
Commitment,
Participation,
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”
How Much Time Devoted to AL?(hours per
year)
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
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
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”
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/emer
gencymed/residency/orthoteaching/index.html
• UCSD Toxicology Teaching Modules