Teaching the Modern EM Resident

Author: Julie S. Sayegh, MD (Clinical Instructor, Simulation Fellow, UC Irvine Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK) & Justin Bright, MD (@JBright2021)

Over the years, the growth of digital technology has changed the way EM residents think about learning.  With the advent of the second wave of the World Wide Web in 2004 (aka Web 2.0), the Internet moved from static web pages where content could only be passively viewed, to dynamic pages that allow users to collaborate, share, and interact with each other in a virtual environment.¹

These technological advances led to an increase in the use of eLearning and to the rise of social media learning platforms such as YouTube, Facebook, Twitter, medical blogs, forums, podcasts, and others.²  In 2012, an EM physician by the name of Mike Cadogan even coined the term “FOAM” (Free Open Access Medical Education) to describe the vast amount of medical information available on the web.^{3, 4}

Current EM residents, as part of the Millennial Generation (born between 1981 and the present), now see this new technology as a way of life, and feel the need to be connected online at all times.^5,6  As a result, many EM residents have abandoned the traditional lecture hall and textbooks, and have taken to their electronic devices and the World Wide Web for obtaining information.

In order to continue providing quality education that meets the needs of the modern EM resident, the type and quality of educational resources that we deliver must also change.

So the question becomes:  How do we use these new resources to guide the education of our current EM residents both on and off shift?

1. Know your audience

To teach the modern EM resident, we must understand how the modern EM resident thinks.  In addition to possessing a greater degree of technological know-how, studies have shown that these Millennials, also known as “Digital Natives,” are more team-oriented and optimistic.  They tend to also be more sheltered, require more structure and guidance with decision making, and feel a higher sense of anxiety and pressure to achieve compared to previous generations.^5,6  Knowing this, residency programs must ensure that they provide more interactive and engaging educational experiences for the modern EM resident to learn.  They must allow residents to stay connected with each other and the program, and provide mentorship that will foster success among this unique group.

2. Encourage FOAM learning: Create your own FOAM, or provide a list of credible FOAM resources

Several studies have shown that learning from different types of FOAM, such as podcasts, blogs, and videos, can be equally as effective as, and even enhance, traditional lectures and didactics.^7,8  However, all educational materials are not created equal.  When it comes to the FOAM movement, some have questioned the quality of what residents are learning.  In order to ensure that they are receiving accurate information, many residency programs are creating their own FOAM resources, such as blogs, podcasts, instructional YouTube videos and medical apps.  Some have chosen to create accounts on Twitter, Facebook, Google Hangouts, and other forums as well.  Here, information considered critical for learning by the program itself can be reposted and shared among the group to maximize resident exposure to credible resources and learning.  In this way, the content can be screened for accuracy prior to distribution.  No time to create your own?  It may also be useful to provide residents with a list of current EM blogs, podcasts, and forums that can be beneficial to their learning experience.  Some of my favorites include the New England Journal of Medicine Facebook feed, and the Life in the Fast Lane and Academic Life in EM blogs.

3. Get them online and connected: Create your own online curriculum or adopt current online resources into resident curriculum

Educational research has shown that learning can be more effective and student satisfaction rates and performance on exams higher after taking online courses as compared to traditional lecture. ^9-13  As a way to encourage eLearning, some residency programs have developed new online curriculum to help their technologically savvy EM residents get online and get connected.^14-16  This includes development of educational modules, ebooks, iBooks, virtual lectures, podcasts, and quizzes.

The following are some basic concepts of instructional design that can help you create a successful online module or course.

In the 1980s, Malcolm Knowles’ theory of adult learning, or Andragogy, stated that adult learners are more experienced, motivated, self-directed, and want to know the reason for learning.^17,18  Because residents are experienced adult learners, they want to know what they need to learn and why.  Online educational modules should, therefore, have a clear set of goals and objectives at the beginning of each course.   The modules can be customized to the skill level of learners, but it must also be clear to the learner how the educational module pertains to their job or task at hand, such as patient care.

When developing a module, consider incorporating whole-task instruction, or guided discovery based on case-based learning.²  Guided discovery mimics the way in which we learn on shift, and challenges the resident to think critically about the choices they make and the information presented as they go through the module.  Several examples of this exist today that are part of FOAM, such as online radiology websites, ACLS podcasts, and virtual lectures.

For each module, it is also important to ensure that the audio and visual components do not overload the learner.  Contrary to popular belief that educational materials should incorporate text, audio, and visual components to accommodate various learning styles, combinations of these three elements can be catastrophic to the learning process.  Research has shown that combining more than two of these elements increases the learners’ cognitive load,² or the amount of mental effort being used for memory and learning.  It is preferable to use visual media with spoken audio, or visual media with text, but not both, as this may hinder comprehension and ultimately, the ability to learn.

Lastly, a good online module should include elements of expert modeling.² As Millennials, modern EM residents need more structured and guided instruction.  When residents observe as experts model the desired skill or thought process before being given a chance to implement it themselves, it not only reduces the cognitive load, but also enhances the learning experience.  This can be accomplished by incorporating video media content into the module, such as how to insert a central line, or how to apply vent settings.

If designing and creating online curriculum is not an option for your program, there are several free lecture series, such as EMRAP TV, NEJM Videos in Clinical Medicine, among many others, that can be referenced for resident learning.  These can also be incorporated into their educational curriculum.  iBook also offers several demo and EM-related electronic books that can be downloaded for free or for a nominal fee.  Quizzes can be created based on these lectures to ensure resident compliance with assignments and learning.

4. Provide 24 hour access to learning

To maximize resident exposure to these electronic materials, many residencies provide their learners with devices (such as ipads) for viewing online learning materials.  Others may offer an educational grant for such devices.   Residencies should continue to encourage the use of these devices not only to provide residents with accessible information, but to also help them stay connected.

Many residency programs are now also adopting Learning Management Systems (LMS), such as Moodle, Edmodo, Schoology, ConnectEDU, Canvas, etc, to provide 24hour online access to curriculum for their residents.  LMS platforms are like classrooms that are open 24hours a day.  Residents can access the platform by logging in with a username and password.  The LMS can be used to provide online instruction (articles, videos, podcasts, quizzes, virtual lectures), to track the progress of residents’ performance (test scores and grades), and to provide access to open forums for discussion.^19,20  Instructors who manage the platform can also easily add and remove items and links from the curriculum to help guide learning and keep the curriculum current.  This type of eLearning encourages self-directed learning, and keeps the resident connected with important information, their peers and instructors.

5. Give them a face-to-face experience to remember

Although there has been a mass movement toward social media, the FOAM movement and online learning, some feel that these adjuncts to learning should not replace, but only supplement bedside and face-to-face teaching.^{21, 22}   There is no question that face-to-face teaching allows for direct assessment of the residents’ professionalism, patient care, and procedural competence.  They also help to identify gaps or confusion in resident knowledge, to solidify learning, and to allow the instructor to serve as a role model for the resident.^21,22

So what is the best way to incorporate new educational technology such as FOAM and online curriculum into face-to-face teaching?  Use the Flipped classroom model!  In the flipped classroom, residents learn new material online from home, and instructors are then free to use face-to-face time during conference or lecture to reinforce learning and address any questions the residents may have.^4,23  The online material can include modules developed by the residency program, chapters from an ebook, podcasts, virtual lectures, or any other form of FOAM.⁴  The flipped classroom also caters to Millennial EM residents’ learning style; to be self-directed, online, and connected.

Outside of the lecture setting, several “on-shift” strategies can also help enhance resident learning.   The SPIT diagnosis (learned while in attendance of the ACEP Teaching Fellowship, 2014) which stands for Serious, Probable, Interesting and Treatable, is a technique that challenges the resident to come up with a broad differential diagnosis depending on patient signs and symptoms.  SPIT encourages residents to “think outside of the box,” and helps to improve their critical thinking skills.  Also, incorporating the SPIT technique while on shift increases the interaction between faculty and residents, and encourages better rapport and camaraderie in the workplace.

Another useful on-shift technique is debriefing. Normally used during simulation sessions, debriefing encourages residents to evaluate and reassess their patient care, and is an effective teaching tool while in the emergency department.  One simple and easy-to-use debriefing technique is called the Plus-Delta model.  This strategy requires that the resident summarize the events that occurred in the case, reflect on the things they felt they did correctly (the Plus), and things they would change (the Delta).^{24, 25}  It also allows the resident time to ask any questions they may have for clarification.

Some residencies also encourage on-shift learning by having several ipads set up in the charting area that display board review questions.  This helps to foster knowledge attainment during shift down time.

As digital technology continues to expand, the above suggestions can help bring more of the technology that surrounds our modern EM resident learners into the work and learning environment.  Thanks to the rise of the FOAM movement, there are already several established, affordable resources that can be incorporated into the resident curriculum.  Online learning can make learning more interactive and engaging, and help keep the resident connected to information at all times.  Residencies have to change the way in which we deliver information to our modern EM residents to accommodate their educational needs!!

References / Further Reading

1. What Is Web 2.0. (n.d.). Retrieved September 3, 2015, from http://www.oreilly.com/pub/a/web2/archive/what-is-web-20.html
2. Clark RC, & Mayer RE. e-Learning and the Science of Instruction: Proven Guidelines for Consumers and Designers of Multimedia Learning. 2011. John Wiley & Sons.
3. Mann C. (2013). FOAM: the Internet, social media and medical education. EMJ. 2013; pp 1-4.
4. Nickson C, Cadogan M.  Free Open Access Medical education (FOAM) for the emergency physician. Emergency Medicine Australasia.  2014; 26, 76–83.
5. Rivera B, Huertas M. Millennials: Challenges and Implications to Higher Education. Faculty Resources Network, 2006. Retrieved from https://www.nyu.edu/frn/publications/millennial.student/Challenges%20and%20Implications.html

6.     Keeling S.  Advising the Millennial Generation. NACADA Journal.  2003.  23(1 & 2):30-36.

7.     Deiorio N,  Fitch MT,  Jung J, Promes S, et al. Evaluating Educational Interventions in Emergency Medicine. Acad Emerg Med. 2012 Dec;19(12):1442-53.

8. Kalludi SN, Punja D, Pai KM, Dhar M. Efficacy and perceived utility of podcasts as a supplementary teaching aid among first-year dental students. The Australasian Medical Journal. 2013. 6(9): 450–457. http://doi.org/4066/AMJ.2013.1786
9. Campbell M., et al. Online vs. face-to-face discussion in a Web-based research methods course for postgraduate nursing students: a quasi-experimental study. Int J Nurs Stud. 2008; 45(5):750-9.
10. Levinson AJ. Effectiveness study of an online anaphylaxis training program for school personnel: overview of methods for a pilot study in a large Canadian school board. Allergy Asthma Clin Immunol. 2010; 6(Suppl 1): P12.
11. Means B., et al. Evaluation of Evidence-Based Practices in Online Learning: A Meta-Analysis and Review of Online Learning Studies. U.S. Department of Education Office of Planning, Evaluation, and Policy Development Policy and Program Studies Service. Center for Technology in Learning. 2009.
12. Velan GM., et al. Integrated online formative assessments in the biomedical sciences for medical students: benefits for learning. BMC Med Educ. 2008; 8:52.
13. Pourmand A, Lucas R, Nouraie M. Asynchronous web-based learning, a practical method to enhance teaching in emergency medicine. Telemed J E Health. 2013 Mar;19(3):169-72. doi: 10.1089/tmj.2012.0119.
14. Chu LF, Ngai LK, Young CA, Pearl RG, Macario A, Harrison TK. Preparing Interns for Anesthesiology Residency Training: Development and Assessment of the Successful Transition to Anesthesia Residency Training (START) E-Learning Curriculum. Journal of Graduate Medical Education, 2013; 5(1): 125–129. http://doi.org/4300/JGME-D-12-00121.1
15. Hemans-Henry C, Greene CM, Koppaka R. Integrating Public Health–Oriented E-Learning Into Graduate Medical Education. American Journal of Public Health. 2012; 102(Suppl 3): S353–S356. http://doi.org/2105/AJPH.2012.300669
16. Kulier R, Gülmezoglu A, Zamora J, et al. Effectiveness of a clinically integrated e-learning course in evidence-based medicine for reproductive health training: A randomized trial. JAMA. 2012; 308(21): 2218–2225. http://doi.org/1001/jama.2012.33640
17. Abela J. Adult learning theories and medical education: a review.  Malta Medical Journal.  2009; 21(1):  11-18.
18. Taylor B, Kroth, M. Andragogy’s Transition Into The Future: Meta-Analysis of Andragogy and Its Search for a Measurable Instrument.  Journal of Adult Education. 2009; 38(1): 1-11.
19. Chu L, Young C, Ngai L, et al. Learning Management Systems and Lecture Capture in the Medical Academic Environment. International Anesthesiology Clinics.  2010; 48(3): 27-51.
20. Johnson E, Hurtubise L, et al. Learning management systems: technology to measure the medical knowledge competency of the ACGME. Medical Education.  2004; 38: 599–608. doi:10.1046/j.1365-2929.2004.01792.x
21. Sherbino J, Frank J. The Power of Social Media to Transform Medical Education. Postgrad Med J. 2014; 90(1068): 545-546. Retrieved from http://www.medscape.com/viewarticle/832133
22. Jordan J, Jalali A, Clarke S, Dyne P, Spector T, Coates, W. Asynchronous vs didactic education: it’s too early to throw in the towel on tradition. BMC Medical Education. 2013.  13(1): 1–8. http://doi.org/1186/1472-6920-13-105
23. Mehta NB, Hull AL, Young JB, Stoller JK. Just Imagine: New Paradigms for Medical Education. Academic Medicine. 2013; 88(10): 1418–1423. http://doi.org/1097/ACM.0b013e3182a36a07
24. Cho SJ. Debriefing in pediatrics. Korean Journal of Pediatrics. 2015; 58(2): 47–51. http://doi.org/3345/kjp.2015.58.2.47
25. Mullan PC, Kessler DO, Cheng A. (2014). Educational opportunities with postevent debriefing. JAMA. 2014; 312(22): 2333–2334. http://doi.org/1001/jama.2014.15741