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					    Asynchronous Learning:
  Getting Your 5th Hour in Sync
              Linda Regan, MD

 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
        Asynchronous in Texas
• Dr. Michael Wainscott

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

Total Async Hours          Lectures
                              42 hours/year     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         -
EMS Base Station Course           8 hours          4 hours
Resident in Charge Mtg            2 hours             -
Resident Transition Mtgs          2 hours             -
                             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
                      UTSW     UT-Houston
ACLS                 8 hours    8 hours
ATLS                 8 hours    8 hours
PALS                 8 hours    8 hours
Neontal Resus        8 hours    8 hours
  Recertification    4 hours    4 hours
  for above
                          UTSW            UT-Houston

ACEP Scientific      3 hours/day (12)   3 hours/day (12)
TCEP Annual           2 hours/day (8)   2 hours/day (8)
SAEM Annual          3 hours/day (12)   3 hours/day (12)

Business of EM        12 hour course    1 hour/meeting
                                 UTSW        UT-Houston
MedScape CME                        -   ¼ hour/module (20 hrs)
ACEP’s 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                       4 hours
NIH Stroke Scale Certification      -           2 hours
S.A.F.E.R. Training                 -           2 hours
                              UTSW             UT-Houston
Scholarly Project             4 hours              -
Performance                   2 hours              -
Improvement Project

Journal Club            2 hours/journal club       -
Resident as Teacher           1 hour               -

Chart Review                  1 hour               -
Monthly Board Review      2 hours/month            -
• 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
  – Using GoogleDocs, data automatically entered
    into spreadsheet for review
• 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   UT-Houston
  The program director
must monitor all activities
for resident participation
There must an evaluation

  There must be faculty

   The activity must be
     monitored for
Asynchronous Education:
 Fad or Paradigm shift?

       Douglas M. Char, MD
   CORD Academic Assembly 2011
   Asynchronous Didactic Balance
Pros                                 Cons
• Allows residents to maintain       • Difficult to ensure consistent
  “conf” credit when sick, on          curriculum and educational
  vacation, post call, off-service     experience
• Reinforces self-directed           • Cost
                                     • Need to ensure material
• Match didactic emphasis with         remains “current/updated”
  clinical rotation
                                       and available (circulation)
• Use outside resources to
                                     • Less time to cover other
  strengthen curricular deficits
                                       portions of the curriculum
• Customized curriculum meets
  individual interests               • Resident may gravitate to
• Better attention during              strengths and avoid areas of
  conference (less hours sitting)      weakness under guise of
         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
   – 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
                                No commercial interest in products selected
• 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,                              Emedhome                Mattu 1hr
             How the experts think—Trauma,                                  Emedhome                Betzner and Plant 1h
             Ten Ways to Lose and Airway,                                   CME download            Peter DeBlieux 1 hr
             Critical Cardiology in the Emergency Department ,              CMEdownload             Jorge Martinez 1 hr
November          Are c-spine plain XR obsolete?                            Emedhome                Bart Besinger .5hr
                  Do patients pith themselves?                              Emedhome                Geoff Hayden .5hr
                  Tox Myths and pseudomyths                                 Emedhome                Andrew Stolbach .5hr
                  When the ticker starts to flicker                         Emedhome                Kevin Reed .5hr
                  ALTE Simplified                                           CMEdownlaod                    30 min
                  Life Threatening Rashes                                   CMEdownload                     35 min
                  Mistakes to Avoid in Kids                                 CMEdownload                     38 min
                  Quickie Snappies Day 1                                    CMEdownload                     26 min
December          Rads in Pregnancy                                      Emedhome                   Jeff Ufberg .5 hrs.
                  Review of new AHA guidelines                           EMCast                     Amal Mattu 1.5 hrs
                  Five articles that may change your practice.           Emedhome                   Kevin Curtis, .75hr
                  peds head injury, peds status, some airway, ?etomidate in sepsis
                  A skeptics guide to reading the medical literature, part 2                        Joe Lex, 1hr

January, 2011 Drugs and Devices 2009 That Might Change Your Pratice                                 Joe Lex 1 hr.
              (1)AHA Guidelines: Dysrhythmias; (2) Aortic Dissection; (3) Lower GI                  Amal Mattu 1.5 hr
              Bleeding; (4) Pulmonary Embolism
              Stroke   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
• 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/   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          • Semi annual examination
    PEER series
                                   • Review of in-service
    CORD Question Bank              examination
    AAEM: A Focused Review of
     the Core Curriculum
    1000 Questions to help you
     pass the emergency medicine
    Emergency Medicine:
     Examination and Board
               EMRAP Podcast
Component                   Evaluation
• Resident choice of        • CME questions:
  monthly podcast session      – Pretest/Post-test
                            • Best of EM:RAP
       Senior Directed Curriculum
Components                    Evaluation
• Career Development Skills   • Mentored program with
   –   Time table               attending physician panel
   –   CV preparation         • Small group format
   –   Networking
   –   Interview skills
   –   Job selection
   –   Pitfalls from Alumni
   –   Contract evaluation
   –   Negotiation
                          Skill Labs
Component                          Evaluation
 ENT                              • Precepted activity
    Epistaxis Management
    Nasopharyngeal Scope
                                   • Pretest/Post-test
 Ophthalmology                    • Audience response system
    Slit Lamp Examination
    Visual Diagnosis Rapid Fire
 Orthopedics
    Rapid Ortho Imaging and
    Splinting Lab
    Dislocation/Reduction
Component                    Evaluation
• Customized individual      • Individually precepted
  simulation session           activity
  focusing on resident and   • Interactive
  residency assessed need    • Pretest/ Post-test
Component                        Evaluation
• Pre-approved on-line           • Interactive
  modules                        • Pretest/Post - test
   – Adult Procedural sedation
   – Pediatric Procedural
   – Trauma Triage
   – SBAR Communication
   – NIH Stroke Management
Component                       Evaluation
• Lecture development for       • Goals and objectives
  multi-level audiences         • Lecture
   –   Medical students
                                • Summary of audience
   –   Nurses
   –   Undergraduate students
                                • Oversight by physician
   –   EMS/Fire
                                  director of program
Component                         Evaluation
• Hands on practical              • Precepted Activities
  application                     • Interactive
• Weekly ultrasound review
   – Indication for ultrasound
   – Pertinent medical/clinical
   – Quality of images
   – Suggestions for
     Approved Asynchronous Learning
Component               Evaluation
• National Conference   • Varies depending on
• Pediatric               activity
• Oral surgery clinic
  Asynchronous Learning Monitoring
           and Oversight
  Log activities on a Googledoc spreadsheet monthly
  Review approved activities/preceptor quarterly via
   survey monkey and P&C Committee
  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
      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
• 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        -
(ABLS, EMS, Disaster)
Float Instructor          -       -      2
     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
  – Normal, breech, nuchal cord,
  prolapsed cord, shoulder dystocia
• Check-listed and competency-assessed
  Advantages, Disadvantages &
• 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
  – Keep everyone busy without making the groups
    too large
• 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
       Additional Considerations
• Conference Time
  – This takes up ~25% of conference time
  – Thus, the rest of the curriculum is compressed by
     • 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”
   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
• “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?
• Survey Monkey™ online survey
• Recruitment of participants from CORD Listserve
• 6 weeks duration, two e-mailed pleas for
• SurveyMonkey™ calculated percentages of
• 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
•   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 Expected Resident
             Administrative Time
              Unreliable,Sources, 0
               Commitment, 0 0
  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
       Use of AL in Fulfilling Program
• (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
• 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
• 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
• Feinberg School of Medicine EM Radiology
• UCSD Toxicology Teaching Modules