Social Media in the EM Curriculum: Annals of EM Resident Perspective article

Social Media in the EM Curriculum: Annals of EM Resident Perspective article

Hand holding a Social Media 3d SphereThis month marks our second ALiEM-Annals Resident’s Perspective discussion. Similar to the ALiEM-Annals Global EM Journal Club series and the first Resident’s Perspective piece on Multiple Mini Interviews, we will be discussing the most recent Annals of Emergency Medicine Resident’s Perspective piece on the Integration of Social Media in Emergency Medicine Residency Curriculum. We hope you will participate in an online discussion based on the paper summary and questions below from now through August 1, 2014. Respond by commenting below or tweeting using the hashtag #ALiEMRP.

Google Hangout with the Authors

On July 31, 2014, we will be hosting a 30 minute live Google Hangout on Air with Drs. Kevin Scott (@K_ScottMDand Mira Mamtani (@MiraMamtaniPenn), the authors of the Annals of Emergency Medicine Resident’s Perspective paper on the how social media is being used in the EM educational curriculum. Also joining will be Drs. Stella Yiu (@Stella_Yiu), Michael Gisondi (@MikeGisondi), and Seth Trueger (@MDAware). Be sure to tune in! Later this year, a summary of this blog- and Twitter-based discussion will hopefully be published back into the journal.

  • 00:00 Bryan Hayes makes introductions
  • 01:06  Kevin Scott discusses the impetus for writing this paper.
  • 05:40  Mira Mamtani discusses (1) how to engage faculty in the use of social media technologies in residency education and (2) how this fits in with ACGME standards
  • 09:45  Stella Yiu talks about the flipped classroom and tips for success
  • 12:39  Seth Trueger talks about the role of social media in academia as well as about quality assurance
  • 15:05  Michael Gisondi talks about innovative practices at his institution and how to overcome barriers in bringing in “more senior” faculty.
  • 21:23  Wrap up final points and comments by the panelists

Annals of EM Resident Perspective Article

Scott KR, Hsu CH, Johnson NJ, Mamtani M, Conlon LW, DeRoos FJ. Integration of Social Media in Emergency Medicine Residency Curriculum. Ann Emerg Med. 2014 Jun 21. [early release] PMID: 24957931. Free PDF download (2.1 MB)

Introduction

This article is excellent overview of the current landscape of social media use and perspectives specifically in the graduate medical education world of EM. The authors, based in the University of Pennsylvania, share not only an introduction to social media and examples of best practices in medical education, but more importantly discuss the several barriers to more mainstream adoption of digital technologies.

Modalities and concepts discussed included:

  1. Blogs
  2. Podcasts
  3. Videocasts
  4. Twitter
  5. Google Hangout
  6. Flipped classrooms

Barriers discussed included:

  1. Generational gaps may lead to a lack of familiarity with social media
  2. Social media, such as Twitter, may cause a distraction and disrupt other aspects of residency education
  3. Core knowledge is currently less represented in social media content
  4. Residents may over-rely on social media education without critically appraising the literature
  5. Quality assurance is a constant concern amongst educators because social media resources, such as blogs, typically lack peer review before publication
  6. Learners may be overwhelmed by information overload using social media
  7. There is no validated study showing an objective improvement in resident knowledge and learning with social media
  8. As with everything in social media, privacy and professionalism issues are an underlying concern

FOAM Discussion to Date

The role of social media in the future of medical education is one of the most discussed topics among educators and students in the FOAM community. A comprehensive review of content produced since 2013, accomplished using FOAMSearch and Google queries, revealed 10 blog posts, 4 podcasts, and 2 open access journal articles discussing the role of social media in emergency medicine education. These resources, listed below, are a great overview of the many perspectives already shaping the role of social media in medical education. For those new to the idea of FOAM and social media in academia, be sure to check out Chris Nickson’s overview of FOAM at Life in the Fast Lane.

Website Title Author Type Country Date
Academic Life in Emergency Medicine New AIR Series: ALiEM Approved Instructional Resources Andrew Grock Blog USA 7/16/14
The Rolobot Rambles #FOAMed and #SMACC: Revealing the Camouflaged Curriculum Damian Roland Blog United Kingdom 7/1/14
The Poision Review Must-read: getting started in online emergency medicine education and FOAMed Leon Gussow Blog USA 6/28/14
Emergency Medicine Cases Social Media & Emergency Medicine Learning Anton Helman Podcast Canada 6/24/14
Emergency Medicine Cases Best Case Ever 25 Rob Rogers on Social Media in EM Education Anton Helman Podcast Canada 6/18/14
Ultrasound Podcast Social Media and Medical Education. #FOAMED talk from #ACEP13 Matt Dawson Podcast USA 5/14/14
ACEP Now Tweets from Emergency Medicine-related Conferences Relay Latest Research About Social Media and Critical Care, Resuscitation Procedures, Ultrasounds, and Toxicology Jeremy Faust Blog USA 5/7/14
The Skeptics Guide to Emergency Medicine Tiny Bubbles (#FOAMed and #MedEd) Ken Milne Podcast Canada 4/25/14
Emergency Physicians Monthly PRO/CON: Why #FOAMed is NOT Essential to EM Education Nicholas Genes Blog USA 4/7/14
Emergency Physicians Monthly
PRO/CON: Why #FOAMed is Essential to EM Education
Joe Lex Blog USA 4/7/14
AAEM/RSA Blog FOAM — This is not the future of medicine, it is medical education NOW! Meaghan Mercer Blog USA 7/23/13
Emergency Medicine News News: How Twitter Can Save a Life Paul Bufano Open Access Journal USA 4/12/13
ACEP Now
FOAMed appeal is simple: Get more, pay nothing
Jeremy Faust Blog USA 2/1/13
Emergency Medicine News Breaking News: Don’t Call It Social Media: FOAM and the Future of Medical Education Gina Shaw Open Access Journal USA 2/1/13
Academic Life in Emergency Medicine Lost in translation: What counts as asynchronous learning? Nikita Joshi Blog USA 1/18/13

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Featured Discussion Questions

The ALiEM team poses the following questions to explore current practices with social media and medical education, and perceptions about the benefits and drawbacks of this educational modality. If you have additional questions, feel free to pose them!

  • Q1. Educators: What are the biggest barriers for educators and how to overcome them?
  • Q2. Learners: How do we engage learners once the tech-innovation is employed? If you build it, they won’t necessarily come!
  • Q3. Programs: What are other examples of actual or potential innovations in GME that wasn’t described in the paper?

Please participate in the discussion by answering either on the ALiEM blog comments below or by tweeting us using the hashtag #ALiEMRP. Please denote the question you are responding to by starting your reply with Q1, Q2, or Q3.

Best Blog and Tweet

NEW! Contest for Best Blog Comment and Tweet

Thanks to Dr. Henry Woo and his colleagues in the Twitter-based International Urology Journal Club series (#urojc) hosted by @IUroJC, we are also implementing a contest for the Best Blog Quote and Best Tweet. What, emergency physicians – competitive? No… The winners will be announced in our Annals of EM publication curating this discussion.

Disclaimer: We reserve the right to use any and all tweets to #ALiEMRP and comments below in a commentary piece for an Annals of Emergency Medicine publication as a curated conclusion piece for this Resident’s Perspective publication. Your comments will be attributed, and we thank-you in advance for your contributions.

Bryan D. Hayes, PharmD, FAACT, FASHP

Bryan D. Hayes, PharmD, FAACT, FASHP

Chief Science Officer, ALiEM
Creator and Lead Editor, CAPSULES series, ALiEMU
Clinical Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School
Bryan D. Hayes, PharmD, FAACT, FASHP

Latest posts by Bryan D. Hayes, PharmD, FAACT, FASHP (see all)

Scott Kobner
ALiEM New Submissions Editor
Medical Student
New York University School of Medicine
2014-15 ALiEM-EMRA Social Media and Digital Scholarship Fellow
  • Jeffery Hill

    Q1. & Q2.

    At our residency training program, University of Cincinnati, we sought to integrate social media into our curriculum in a couple of different ways in the past year (an online flight physician orientation curriculum and an informal article discussion forum on Google+). My experience with these initiatives has taught me that Q1 and Q2 are pretty much one in the same. The biggest barrier facing educators is the development of effective strategies to increase learner engagement. The ultimate goal of any of these initiatives should be to create a robust venue for interaction between learner and instructor and to foster a meaningful learning experiences. Meaningful learning is supremely important. As pointed out in the article, “Having residents take quizzes related to material presented through individualized interactive instruction might demonstrate participation and compliance, but not necessarily understanding.” (Scott, et al, 2014)

    How then do we, as educators, foster the cognitive presence of our learners in these activities, thereby increasing opportunities for the meaningful transfer or generation of knowledge? At the very minimum, it requires a dedicated instructor (or better yet several instructors) who have designed experiences that challenge and interest their learners and who are available and responsive in online discussions. It requires experiences that are easily accessible to learners (push notification features for new posts/discussion comments, easily accessible short vodcasts/podcasts/blog posts that can be easily consumed by busy residents). It requires the establishment of a safe learning environment (may mean a private discussion board instead of open social media venues such as Twitter). It requires active inquiry by the instructor – seeking individual or group knowledge gaps in their learner community. It requires an accurate assessment of the technologic proclivities of your learner group (which social media sources are they most comfortable with, etc). In short, it requires work – and a lot of it.

    One model or framework that can be used to help create the meaningful asynchronous online educational experiences in a residency curriculum is the Community of Inquiry framework first proposed by Garrison, Anderson, and Archer in 2000. This model proscribes that meaningful educational experiences come from the “development of three interdependent elements – social, cognitive, and teaching presence.” (Garrison, et al)

    References:

    Scott KR, Hsu CH, Johnson NJ, Mamtani M, Conlon LW, DeRoos FJ. Integration of Social Media in Emergency Medicine Residency Curriculum. Ann Emerg Med. 2014 Jun 21. [early release] PMID: 24957931

    Garrison, D. R., Anderson, T., & Archer, W. (2000). Critical inquiry in a text-based environment: Computer conferencing in higher educationmodel. The Internet and Higher Education, 2(2-3), 87-105.

    Garrison, D. R., Anderson, T., & Archer, W. CoI Model. Accessed from https://coi.athabascau.ca/coi-model/, Monday, July 28, 2014.

    • Thanks for the great response.

      I can certainly imagine how engaging learners with FOAM/social media in an EM curriculum is one of the biggest barriers for educators attempting to modify their instruction of students. However, this barrier is present within current educational practices, too.

      In relation to more traditional education modalities, do you think that this learner engagement challenge is uniquely more difficult with FOAM? Or do you feel that, at baseline, FOAM has a better or at least equivalent engagement level when compared to, say, conference and journal clubs?

      • Jeffery Hill

        Great point. Engagement is difficult in education in all its forms. In my opinion it is more challenging with an asynchronous educational module. When you are face to face with the learner you can “read the audience” and adjust your teaching style on the fly if it seems that you are losing them. That is a much more challenging proposition when you are responding to discussion board posts/on a comment thread. In addition, to maintain the teaching presence in an online discussion board requires sustained and consistent effort over a long period of time (weeks maybe months depending on the design of the curriculum). To deliver a good lecture requires effort over the span of an hour or so (in addition to the hours spent designing the lecture).

        What I found when doing the online flight physician orientation was that there were some learners who simply did not like to use online resources/discussion boards/podcasts/videos. And, though I am still crunching some numbers, it doesn’t seem like there was a “green eggs and ham” effect. After they tried it out, after the completion of the curriculum, those who didn’t like these tools at baseline still didn’t like using asynchronous or online educational tools. I would say that FOAM in particular has greater engagement because the learners that seek it out currently are those that are already interested and engaged. I think the more intriguing and challenging question is how do you logistically integrate online educational resources/experiences into a residency wide curriculum where you have a mix of learners with varying technological proclivities.

        • Thanks for the excellent insight.

          I think the effort for teaching presence, as you say, is a very under emphasized challenge for educators. From my experience as a learner, I think you are totally spot on. The best online learning environments I have been a part of involved incredibly dedicated educators who were highly responsive and aware of the trends taking place in their forums or discussion boards.

          For educators accustomed to only involving themselves in an hour or so of lecture, then answering a few questions via email afterwards, the input required to establish an online presence might seem overwhelming. On the other hand, simply using pre-existing FOAM materials to supplement traditional approaches would only require educators to review these resources to discuss them. In fact, this would shift the burden of online presence from educators who would rather operate within more traditional education domains to those who produce FOAM and already engage learners with their content through comments, twitter, etc.

          You make an excellent point about “reading the audience” when educators teach in person. Do you think tools like comment systems, analytics, or content rating systems can serve the same role in the online arena?

          The question of integration is definitely a challenge with the varying technological inclinations of learners. One approach might be to include the same content in various mediums for learners in a central location. As a medical student, I have seen this can be a huge advantage. For instance, if the topic of weekly conference is going to be on PERC, one might consider providing a podcast, a blog post, and a videocast as a primer for discussion. In this way, learners can decide which resource is right for them. Of course, this requires more work on the part of the educator to assemble and review this diverse set of resources, but probably not too much more than the standard literature review they are already accustomed too prior to making a presentation.

          I have also seen residents and students directly engaged in content curation on behalf of their programs for such approaches, which speaks a lot to the learner agency discussed below.

          This approach, while imperfect, I think is still more learner oriented than traditional education modalities. Do you think the same considerations are made for the learning styles of students in traditional approaches?

    • Michelle Lin

      Great point, Jeff, about the perils of implementing technology for technology’s sake. It’s natural to want to try out the newest/ shiniest “toy” out there, whether it be Google+ communities or creating fancy online modules. In the end, it boils down to meaningful design: What’s the best way to engage and effectively teacher learners on the particular content at hand? Then the modality should be chosen based on your answer.

      I hadn’t heard of the Community of Inquiry framework, but the premise makes sense. You need to get buy-in from the learners about the intrinsic value of the content, a strong facilitator presence, and a “safe” community to grow and learn. Like Scott mentions — this is true for education in general.

      Now that we’ve identified these issues, how do we address this? Maybe if we come up with answers, we can apply them to education overall (not just tech/social media innovations in education).

      • Jeffery Hill

        Excellent point about meaningful design! Any big educational effort should start with rigorous curriculum design (problem identification, performance of a general needs assessment, performance of a needs assessment of learner, decisions on the most effective educational strategies to deliver the content).

        I would agree with Dr. Chan that some of the keys in this are involvement of learners in the process and listening to the individualized needs of the learners. Having a stake in the process should lead to more intrinsic motivation (no one wants to see a project they see as their own fail). Offering the carrot of decreased conference lecture time might offer some additional extrinsic motivation for some learners. However I would say that may only hold true if the learners see the online alternative as easier and less onerous than simply showing up to lecture.

        The answers to these issues are not easy and they take considerable time and effort. I think it starts with culture building. In order to fully and effectively incorporate social media into a residency wide curriculum you need to have faculty and residency leadership that accept it as a legitimate form of resident education (affects the normative beliefs of the learners). You have to simultaneously use a variety of social media and online technologies to ensure your learners have the opportunity to use the new resources as a natural component of their education (affects control beliefs). You have to provide extrinsic motivation when appropriate and tap into their intrinsic motivation through mentorship, goal setting, monitoring, and effective performance feedback.

        In sepsis resuscitation, what matters most is paying attention to the individual needs of the patient. In education, what matters most is paying attention to the individual needs of the learner.

  • Q1 / Q3:

    Learner Agency

    One of the aspects that I see in this article was the lack of agency for the learners themselves. I think engagement flows from both making something desirable and fun, but also when you have a true stakeholdership within in. Don’t you think that your residents would read more stuff if it was both high quality AND written by their colleagues??

    Communities of Practice & Situated Learning
    As Dr. Hill has suggested, there are conceptual frameworks that might govern and improve our educational practice here. I would suggest that FOAM is a clear “community of practice” (CoP, henceforth), made up of an ‘expert guild’ but the also many participants in the ‘periphery’ (the novices).(1) As outlined in Lave & Wenger’s theory of situated learning, these novices engage in ‘legitimate’ peripheral practice and learn through this engagement. If we are ever to have some of these peripheral participants become truly engaged members of our CoP, we will need to begin to involve them.

    How I’m working on this!
    Hence, at McMaster U, we’re trying to actively engage our learners in participating and contributing to the online repositories #FOAMed. In the next coming weeks, you’ll see a fair number of new names with the projects I’m working on here at ALiEM (I have a bunch of newbies helping out with ALiEM MEdIC series this week!), but also over at BoringEM (where I’m now assuming a temp job as a managing editor). We experimenting with creating writing and editorial apprenticeships (for both residents and students) overing at BoringEM.org.

    Other Awesome Means of Active, Participatory Engagement
    I think we need to create structures to support learners in both their usage (as this article suggests) but also with the creation of new resources. ALiEM has just launched their formal EMRA and CORD fellowships (2,3), which still remain the ‘gold standard’ I think for fostering a new generation of providers to become engaged citizens within the FOAM world. I have heard rumor that Anton Hellman (@EMCases) is starting to coach learners to create podcasts too!

    Credit and Incentives (Controversy here!)
    Most of us do all this stuff as volunteers, but wouldn’t it be nice if we could help make engagement just a bit more legitimate? Just as some medical schools are giving credit for editing Wikipedia (4), perhaps there can be some sort of ‘credit’ given to those who are engaging in KT and/or review-based scholarship in the FOAM world? I think it is imperative that our community not only train clinicians who can be informed consumers of FOAM, but also those who can be active contributors back to the community. Incentives and fostering mentorship relationships will be key for this aspect.

    Anyways, those are my thoughts.
    Teresa

    1. Lave, J., & Wenger, E. (1998). Situated Learning. Google Books Link: http://bit.ly/1kjRWHW
    2. https://www.aliem.com/announcing-aliem-cord-social-media-and-digital-scholarship-fellowship/
    3. https://www.aliem.com/med-students-aliem-emra-social-media-and-digital-scholarship-fellowship/
    4. http://www.ucsf.edu/news/2013/09/109201/ucsf-first-us-medical-school-offer-credit-wikipedia-articles

    • Michelle Lin

      Yes, LEARNER AGENCY and ENGAGEMENT! In medical education, there’s all this talk about moving from teacher-centered to learner-centered education, but it’s been a slow transition process. It is incredibly hard for educations (myself included) to shift away from giving the stock lecture that I’ve given every year. There’s a growing trend toward less “talking at” (lectures) and more “talking with” (facilitating) learners.

      Your examples of direct mentorship to bring junior learners into the core community of experts are great, but they require a lot of 1:1 mentorship. Fortunately, these mentees you mention are already are quite-self motivated based the Self-Determination Theory, that we discussed earlier. https://www.aliem.com/motivation-and-self-determination-theory/

      I’d propose that the first step in all of education is to figure out how to motivate learners to initiate and invest in their own education experience. This will become paramount as medical education continues to encourage educators to be less “talking at learners” and instead be more facilitators, or “tour-guides” in the museum-like world of online learning.

      • I would argue that all of our medical learners are probably capable of investing in their own educational experiences. Most of them have gotten through the MCAT, through the admissions process, through the match… and what? Now, all of a sudden they become piles of unformed GME clay for us to mould?

        I do not actually think that my mentees are *that* special. (Sorry ladies and gents.) They’ve just all identified their motivations and have learned to ride them. Sometimes, some need the fear of practice or exams to motivate them, so they wait until later. But that, too, can be overcome with frequent progress testing (which we do here at Mac Emerg).

        Also, it’s not one-on-one, it’s one on many – I just mentor them for a bit here and there, separately. And… sometimes at the same time. (Stacking learners allows seniors to mentor juniors… a wonderful concept)… Similarly, my mentors always suggested I form a ‘board of directors’ from which to gleam wisdom and collect ideas.

        Anyways, yes, I think you’re right, we need to figure out how to tap into learner (intrinsic) motivation. But this does not come from us ‘manipulating’ their motivation – it comes by finding a spark and then adding kindling and letting that catch fire and burn… Propelling them forward towards their own self-identified goals. I think often we don’t LISTEN enough to individualized needs, but when we do… that, in and of itself, can be a powerful motivator… knowing you have the ear of a mentor who cares about you as a ends upon yourself, and not a means to some other end.

  • Coincidentally, there’s a very relevant and robust discussion going on over on the most recent MEdIC page about — the distracted learner / absentee audience member during lectures. https://www.aliem.com/medic-series-case-absentee-audience/

  • Anand Swaminathan

    Lots of great comments here already and much of what I have will echo this.

    At our residency, we have slowly moved towards more incorporation of FOAM and SoMe. What I find is that the residents have already embraced much of this. Each of them has their preferred blogs and podcasts. The information has been integrated into their general learning and I hear things on shift that I know echo things they learned from FOAM (mostly because that’s where I learned them too).

    My greatest challenge has been getting acceptance from the senior faculty. I hear a number of arguments against FOAM:
    1 – There is no peer review. How do we know any of this is useful?
    2 – We’ve trained great residents for 20 years without FOAM, do we need it now?
    3 – Residents have limited time. Using it on FOAM detracts from reading the text book, journal articles etc.

    I think all educators have heard these complaints and many of these are discussed in Scott’s article in Annals. I’ve also heard that faculty spending time on this is a waste because the Promotions and Tenure committee doesn’t care.

    How do we break down these barriers? Persistence, patients and relentlessness. I guess these are all the same thing. I’ve had passionate discussions with my chairman for 12 months about the strengths of FOAM and the utility of Individualized Interactive Instruction (I3 or Asynchronous Learning). In fact, we have the discussion every week after conference as more FOAM creeps in. After a year, I’ve finally gotten buy in.

    I think the key is that there must be a faculty FOAM champion (or two). This is the guy who relentlessly discusses the pros of FOAM and how it will benefit resident education but can also address the weaknesses of FOAM intelligently. This champion is also the gatekeeper. They are up on the breadth of FOAM that’s available and so they are able to guide the residents towards high-quality content. This champion must invest a lot of time keeping up on posts and podcasts etc but it’s a critical piece.

    Ideally, that champion is part of the residency leadership and conference curriculum planning. In this position, the champion can slowly work more FOAM into conference. This is what I have tried to do. When residents are planning talks, I steer them towards great FOAM content to help build their talks. I use blogs, podcasts and vidcasts as part of our flip the classroom education. What the faculty (especially the skeptics) see is what we already know will happen. The residents become more passionate about their education as they consume more FOAM. They don’t read less, they actually begin to read more looking at the original literature behind posts and podcasts. Conference becomes more interactive because the residents are better prepared to digest the information we deliver. Even the lectures get better as residents pick up tricks and skills by watching and listening to developed speakers.

    Throughout all of this, learner-teacher feedback must be robust. All of our residents are busy and they work hard. The last thing I want to do is give them hours and hours of reading to do at home. As our year progresses, we’ll seek feedback from them on the quality and quantity of content we ask them to cover before coming in to conference. This also helps us to get information on new things that are out there.

    Clearly all of this is time and labor intensive. Hopefully, programs like the ALiEM Approved Instructional Resources will make some of this easier. In the meantime, it’s vital for us to keep pushing the education world to embrace and develop FOAM. It’s also critical for us to keep an open mind lest we become that older generation closed off to new thoughts and techniques.

    • Bryan D. Hayes

      I really like the idea of a FOAM champion (or two) within the department. Even at my institution where we are fortunate to have several big names in EM education and the FOAM world, it is challenging to break from the traditional teaching model.

      Each Wednesday we have 5 hours of conference. At least one hour is a flipped classroom model where residents read a few review articles on various topics beforehand and then one faculty member facilitates a discussion. Once a month we have journal club as well which is a small group based discussion. We have tried the debate strategy a few times with moderate success. Our M&Ms are generally a lot of discussion as well. Some faculty utilize audience response systems for their talks.

      We haven’t integrated FOAM into the residency curriculum much as of yet. Again, though, we are fortunate to have amazing educators at U of Maryland. Rob Rogers hosts the Teaching Course twice a year. Amal Mattu produces weekly ECG vodcasts (and now resuscitation ones as well) which are widely used in our program. I frequently refer back to past ALiEM posts which are largely based on questions that come up throughout our shifts. Mike Winters hosts the CCPEM podcast, which although not FOAM, is available to our residents. John Greenwood co-created MarylandCCproject.org. Haney Mallemat is part of the RAGE Podcast team and does a tone with ultrasound teaching. Michael Bond, the residency program director, gives national talks on technology and social media in education. Even our program’s twitter account (@UMEmergencyMed) tweets out our free daily pearls (also sent via email) on a different topic each day of the week. So the residents are exposed to FOAM frequently, even if not in the official curriculum.

  • Robert R Cooney

    Q3: Programs: Michelle asked me to talk about our program. I also wanted to take a step back and think about this from an educational design perspective.

    So what do we do? Looking back, our use of social media, specifically a residency wiki, was born out of a need to maximize faculty time. When our program began, we had the requirement to deliver 4 hours of didactic education a week and 4 faculty plus 8 learners to do so. Our learners were junior and our faculty didn’t want to lecture every week, so we asked the “what if we did this instead?” question. We decided to implement a hybridized small group approach based on assigned reading, essentially a low-tech flipped classroom. Initially, we used a cloud-based file service to hold all of the readings. It was atrocious. The articles weren’t organized, articles would be missed, and it was very tough to update the curriculum.

    We needed something better. Enter the wiki. We choose google sites as it was one of 3 recommended platforms for educators and seemed easy to use. Very slowly we redesigned our curriculum. From a needs assessment, we knew that we needed to provide the “core content,” and this in turn helped to define our goals and objectives. We also knew that we needed to support learning and maximize the faculty time.

    The part that we really redesigned is our “instructional methods.” All social media application really falls into this category. These applications are tools that facilitate content delivery but can also be utilized by instructors in a content creation role to expand the learner experience. We can use the tools for projects, sharing learning, and collaboration. Instructional design considers these factors and applies them where needed.

    Back to our program. We started with the basics: content delivery. The content being delivered has significantly evolved in the last 6 years. Initially we used journal articles: classic EM papers and lots and lots of review articles that covered the gamut of the core content. Now that FOAM is so copious, we have begun to incorporate reading of blogs, listening to podcasts, and watching vodcasts. The residents have the yearly schedule when they start and can read ahead if needed or read last minute if time demands overwhelm them. From a faculty perspective, we also can immediately update the curriculum as new material is published. For example, when the age-adjusted d-dimer study was published, we vetted it as a faculty and incorporated it into our VTE module within a week of publication!

    As for our learners, do they engage? Absolutely. Several factors drive this, the most important of which I describe below. At some point, residents will skip the assignments. We understand that they’re “busy” and try to protect them to “do the work” but sometimes they just don’t get the work done. In a qualitative review of our approach, the number 1 factor they cited in for not skipping the work: avoiding the embarrassment of being caught unprepared during the classroom component.

    So, what drives the engagement? Back to the design. Our “classroom” time is very well spent. We use discussion as a way of teaching. Our faculty really are “guides on the side.” We use a variety of teaching methods, ranging from checking understanding by having the learners summarize the content of the articles, building a shared mindmap, and projects, such as creating their own podcasts/vodcasts and protocols. Residents will also tweet under the #EMConf hashtag, although the buy-in for this is still evolving. By coming alongside our learners instead of being the “Sage on the stage” we have rich conversations, ask lots of questions, build shared mental models, and promote the community of practice that was discussed above.

    It’s been an incredible journey, one that continues to evolve as FOAM matures. Looking forward, I’m excited about the focus that flipped and blended learning is receiving. My one fear is that the tools and content delivery receive more of the attention than what really matters: faculty and learners learning together in a COP.

    • Thanks for sharing Rob. Kudos for implementing a really innovative curriculum. Some points that I noted that are key —
      1. Instructional design thinking is important. Social media technologies are only tools like hammers, wrenches, screwdrivers. It’s up to use to learn when and how to use them appropriately.

      2. Learner peer pressure works.

      3. Learner engagement depends on not only learners but the educators/facilitators.

      QUESTION: How did you get so many faculty to “buy into” this more evolved educational use of classroom time? I find that being a facilitator is more challenging (less scripted) than being a lecturer with rehearsed slides.

      • Robert R Cooney

        Great question! When we started the obvious buy in was saving time; we wouldn’t need to prepare slide decks every week to lecture. As the program has matured, I think there are multiple “motivators.”

        The first falls in line with Daniel Pink’s “autonomy, mastery, purpose” concepts from SDT: faculty get to choose what module(s) they run every month and how to teach them. In addition to our 2 hour small group discussion, we do an hour of sim and an hour of lecture (invited guests)/M&M/or QI projects. Each month we get a list of the needs and we get to choose where to invest our time for the month.

        It’s also pretty amazing to see the small groups in action. We have amazing learners and I think that lecturing “silences” some of the brilliant insights that they can reveal. Small groups run in way where they feel “safe” can lead to some great questions, uncover important learning needs, expose the hidden curriculum and variation in practice. On more than one occasion we’ve had faculty in a friendly debate on why something should or shouldn’t be done (antibiotics for strep anyone?)

        The real time curriculum updates prompts faculty to be lifelong learners as well. We each take 2-4 content areas and scan the literature for new material that should be incorporated. Since everything is on a wiki, we can take modules and completely overhaul them will little effort. I recently did this with our abdominal pain intro module. I realized after running it that the creator rushed right into the core content without providing a general overview of “abdominal pain” so I scrapped the old reading and added new articles about abdominal pain, imaging, and lab testing. The learners love this as well because they can suggest the same. If they find cool content, they send it to us. We also take their feedback seriously and eliminate articles/podcasts that they didn’t find useful.

  • Stephen Smith

    I and a lot of people use ECGs and cases from my blog (Dr. Smith’s ECG Blog) to make presentations.

    It
    is simple to search the blog, find the case, click on the ECG to
    enlarge, then right click and copy the image to place into a ppt or
    keynote.

    Many have told me it has made ECG teaching much better than before.

    I have used it to create a 32 hour ECG course for our residents.j

    Steve Smith

    • Thanks for sharing your experience, Steve. I too have found a few of my Paucis Verbis cards on an occasional resident slide or two during conference. Learners and educators are always looking for well-designed, quality content. Blogs seem to be today’s version of the textbook, whereby the textbook index section is replaced by Google Search and FOAMSearch.

  • Javier Benítez

    This is quite an interesting paper and a great discussion. A curriculum, quite a broad concept, is created in an educational setting to support different educational activities that are influenced on how we think learning happens. Furthermore, we are all influenced, implicitly and explicitly, by different learning philosophies which may be evidence informed or not (https://www.aliem.com/clinician-educator-agent-for-change/). Although we can dissect the curriculum into its different components, the sum of its parts is not equal to the whole. If we view the curriculum as a complex system we should also presume that modifying, adding, subtracting any of its parts will in turn affect the whole system.

    Our current view of learning, as an individualistic endeavor performed in solitary not affected by others or with the aid of educational tools, has been our only way of addressing learning for quite some time. Paavola et al. have addressed three metaphors of learning metaphors which go beyond the information acquisition metaphor to learning theories which include learning in a social community, and learning as knowledge creation. The danger, as Sfard warns “too great a devotion to one particular metaphor can lead to theoretical distortions and to undesirable practices.” Although I agree with the barriers mentioned in the paper by Scott, et al. I believe we should also mention that our current view of learning, mainly as acquisition of knowledge, skews current curriculum development that may negatively bias the use of technology as learning tools. A comment in another post in this blog by Justin Hensley stating that “…teaching theory is poorly explained in most residencies…” (http://disq.us/8jgzhr) supports the view that lack of knowledge of learning theories might also contribute to poor curricular practices.

    Learning theories give us a framework with which to describe how learning might happen under certain circumstances. If we also consider the different metaphors of learning (acquisition, participation, creation) we should be able to see how Social Media which “depend on mobile and web-based technologies to create highly interactive platforms through which individuals and communities share, co-create, discuss, and modify user-generated content.” (http://en.wikipedia.org/wiki/Social_media) can support learning. Nowaday our Personal Learning Environments (https://www.aliem.com/creating-a-personal-learning-environment/) are not only made up of immediate peers and experts, but also technological tools which enable us to connect to the Internet within seconds. PLE’s can also aid learners with pedagogical practices that support self-regulated learning which as stated by Dabbagh et al. The social media platforms as described by Scott et al. provide us with plenty of affordances to support learning theories such as social constructivism, situated learning, and others. But as mentioned in the paper there are barriers to their use.

    Some of the barriers mentioned by Scott et al. are not unique to Social Media. For example, medical education has always been burden with information overload as reported by Anderson, et al. in 1980. One way to alleviate information overload and decison making is by training physicians on information management with the aid of technology (https://www.aliem.com/learning-information-management-instead-of-evidence-based-medicine/). Critically appraising the literature and quality assurance should not be performed only because information is on the internet. Learners should be encouraged to actively practice critical thinking on their thinking as well as all other resources (https://www.aliem.com/critical-thinking-minimizing-not-knowing-what-you-do-not-know/). They should be encouraged not only to consume knowledge, but also to participate in its critique and creation.

    Online scholarly practices are fairly new, an area widely explored by multiple authors in the literature (https://www.aliem.com/medium-change-culture). It is not surprise, then, that for other practitioners might find it difficult to relate to this practice as stated in the new AIR series in this blog “we have observed residencies struggle in evaluating which blog posts and podcasts are appropriate and high quality for resident education.” (https://www.aliem.com/new-air-series-aliem-approved-instructional-resources). This might be the case, but as reported by Scott et al. other residency programs have integrated the use of Social Media in their curriculum. This shows that educational practices are not uniformed throughout residencies where local cultures differ from place to place, sometimes even from person to person (http://shortcoatsinem.blogspot.com/2014/05/i-heard-it-on-some-podcast.html).

    I think the use of Social Media to engage learners in the acquisition, participation, and creation of knowledge should be explored on the basis of different learning theories. Learning theories are frameworks which help to describe how learning might occur under certain circumstances. Some of the barriers in the integration of Social Media in the curriculum are not unique to the use of technology in education. The use of technology should be to support effective pedagogical practices which include self-regulated learning, critical thinking, information management, and more. The Internet will not go away, so the affordances of online scholarly practices should be further explored.

    Paavola et al http://rer.sagepub.com/content/74/4/557.short
    Sfard http://edr.sagepub.com/content/27/2/4.short
    Scott, et al. http://www.annemergmed.com/article/S0196-0644(14)00489-2/abstract
    Anderson, et al. http://www.ncbi.nlm.nih.gov/pubmed/7366494
    Dabbagh, et al. http://www.sciencedirect.com/science/article/pii/S1096751611000467

    • Thanks for your response, really great insight here. I agree with you completely: many of the challenges posed by social media are non-unique when one considers medical education as a whole. I think true opponents of FOAM incorporation only view them as drawbacks because they have grown accustomed to the “standard of care” of traditional education and have been satisfied with the outcome of great residents for years (as Dr. Swaminathan mentioned above).

      How do you think we can address one of the core issues you bring up: the ignorance of learning theories that contributes to poor curricular design? And one step further, who should be responsible for solving this problem?

      • Javier Benítez

        Thanks for your reply Scott. To start off, I think there should be a new specialty in medical education: Clinician Educator, follow link for the blog post (https://www.aliem.com/clinician-educator-agent-for-change/). In an ideal situation, I think curriculum design should be at the local level as long as there are people with a good handle on education such as the Clinician Educator. Curricular practice always comes down to the local culture.

        Interesting enough a recent qualitative research from the UK by Sabel et al. described a group of physicians and scientists who found their identity as educators challenging. There needs to be an encouragement to value educators who truly identify themselves and demonstrate scholarship of teaching and learning in the medical profession. In another publication by van der Vleuten et al. might bring more light into this issue, they conclude “If we take the evidence seriously, our educational practice will look quite different to the way it does now.” This latter review by van der Vleuten looked into different educational strategies such as the flipped classroom, cooperative learning, feedback, mentoring, elaboration, learning as a social context. The importance of this review is to inject evidence into the curriculum and look into various learning theories, learning and teaching strategies that support the development of expert physicians.

        There are multiple learning theories out there and one of the most studied one is cognitivism. Even though we cannot measure or visualize learning cognitive psychologists look into learning as a process that occurs in the mind. This is in contrast to behaviorism which does not take into account the thinking process because it is not visible and/or measurable. In a recent published book, called “Make It Stick”, Roediger III et al. address some of the evidence behind learning and teaching strategies for long term retention. The most common curriculum design is based on organ systems or subjects arranged in “blocks” of 4 to 8 weeks. This set up lends itself to massed learning which is not conducive for long term retention. If the learner wants to accomplish the material for long term retention he/she needs to employ spaced repetition while trying to keep up with the curriculum. As you can imagine this might pose great difficulty and most likely lead to superficial/strategic learning to pass exams rather than to master the material. What cognitive psychologists have found is that interleaved practice is a more effective method for long term retention than block practice see image from Roediger III, et al. on item recall tests.

        If an effective pedagogical practice is established the question becomes “how can Social Media facilitate, augment this practice?”. Twitter can be used to publish questions using interleaved practice. An example of this is @EDUltrasoundQA (https://twitter.com/EDUltrasoundQA) from Ohio State. A Wiki/Blog/GoogleDocs can be set up to answer these questions and be discussed as a group. The latter activity supports a social constructivism learning theory where knowledge is co-constructed in a group of individuals. The learner also participates as part of a community of practice where the instructor can “monitor” the learners and help those that might be in need.

        This is just one example, but pedagogy should come before technology. So far we are unable to measure learning so we assess performance, the problem is that the way the curriculum is set up we are probably measuring high retrieval strength instead of long term retention. Current practices should be thoroughly re-examined and replace that which lacks evidence for desirable outcomes (long term retention, self-regulated learning, transfer, etc). As van der Vleuten has suggested, we should look into the current evidence and explore which practices are better suited for today’s development of experts.

        Sabel et al. http://www.ncbi.nlm.nih.gov/pubmed/25054418
        van der Vleuten et al. http://link.springer.com/article/10.1007/s40037-014-0129-9/fulltext.html
        Make It Stick http://www.amazon.com/Make-It-Stick-Successful-Learning/dp/0674729013
        Roediger III et al. http://www.sciencedirect.com/science/article/pii/S2211368112000915
        Image source: http://belmontteach.wordpress.com/2014/06/08/using-cognitive-science-to-inform-curriculum-design/

        • Hi JB:

          Thanks for always being an advocate for the clinician educator. I do mostly subscribe to the idea that education is an art and science, both of which are largely not well understood in medical education. And, while I mostly agree with your sentiment, one of the challenges I see is in making medical education inaccessible to the average clinical teacher.

          At one recent conference, I was in a conversation with other junior faculty members, and one of them suggested that listening to the Canadian #meded gurus in EM talk was difficult – arguably impossible. Whereas, I’m mostly done my graduate studies, and have another whole degree in education, I took it for granted that most people would understand their lingo. But just as in any other specialized trade craft, we have started to develop a meded lingo… and are starting to speak in code with in the ‘tribe’.

          As Brian Goldman suggests, there is a not-so-secret language for doctors… but there is also a codified way in which medical educators speak and discuss with one another.

          Medical educators tend to use inaccessible terms like “theory” or “conceptual framework”. We tend to use crazy shortforms like CBME (competency-based medical education) and EPA (entrustable professional activities) – all of which are shorthands for HUGE theoretical frameworks to begin with!!

          The challenge, thus, is for us to find clinicians who can act as translators and engineers bridge this divide. We need folks like you who can translate the #meded mumbo jumbo into accessible concepts (your posts for ALiEM are gold for this!), but we also need to find people who can use these theories and design/implement them into real life applications.

          I struggle to be more of the latter – and I think that regardless of the teaching strategies, the important part is for residency programs to created structured learning that utilizes technology (like social media) and traditional techniques (lecture) in appropriate ways. the use of Kern’s 6 steps of curriculum design, for instance, can be very useful in making a curriculum map for a residency program. But it might not take into account the role in instant feedback at revising content for the NEXT day’s class. Using frequent progress testing to harness test-enhanced learning (TEL) is also important, but you might be mindful of whether students might ‘collaborate’ if you administer the test as a weblink they can do at home.

          I think we can discuss implementation science a whole lot more. What are the logistical, cultural and ground-level issues with some of the grand educational theories? What are the faculty requirements for implementing a program based on Ericsson’s theory of deliberate practice for procedural skills? (Hint: It has to do with providing teachers that can help with the feedback loop) Or what does do the ACGME standards and CanMEDS have to do with reconceptualist theories of curriculum design? And how do you manifest those into useful activities?

          But how does all of these theories look different in light of the technologies. The medium CAN BE the message – and alter in such a way that we need new research to figure out the limitations. Take Cognitive Load theory. CLT is an old concept, but the Mayer’s CLT about multimedia education adapts this older concept to a new reality of digital representation.

          I think theory and technology have to evolve side by side. Here are two scenarios that I can think of where technology may change your theories/conceptual frameworks:

          1) Example 1: Lave & Wenger’s theory of situated learning, where they describe the phenomenon of “communities of practice”, is very important to medical educators that explains how clinicians go from peripheral participants to experts within a community. This theory likely explains much of the FOAM community, and yet it never truly anticipated the role that online, asynchronous virtual spaces might play on developing online communities. Adaptations of these theories, but also being open to altering them in light of new phenomenon brought forth BY THE TECHNOLOGY may be a new and intriguing merger of both curricular design and implementation.

          2) Example 2: Imagine, for example, that teaching technologies gather more advanced analytics about usage and interaction… Does this change how we gather Kern’s classic ‘needs assessment’? Does it have to be a big huge step? Or can it be a distributed phenomenon that evolves with the technology? (i.e. instantaneous feedback, etc..) What about a real time clicker system that helps a lecturer receive real-time information about what learners think about their material?

          I think that there is a role of re-thinking education IN LIGHT of new technologies… you never know when they might change your thinking!

          Teresa

          • Javier Benítez

            Thanks for your reply Teresa. Not too soon after entering medical school I knew I would be interested in medical education. For someone who is not an expert or have a degree in education it’s quite an honor to get a reply from you. But I have to disagree with a few points made in your reply.

            I am very grateful to Dr. Lin to give me an opportunity to demonstrate my interest/learning of medical education in this blog. I have written before about how the Internet, although full of information, does not necessarily change the culture (https://www.aliem.com/medium-change-culture/). The Internet has allowed me to access information and publish my thoughts in a scholarly manner. I guess, in other words, it’s allowed me to access and express myself using the language of education and medical education. If someone has the desire to learn more I would tell them to do as I have done ask questions, read the literature, demonstrate what you know, and be open to criticism. Open to criticism is important for a variety of reasons which include learning from others.

            I have learned lots from people in Personal Learning Network (https://www.aliem.com/creating-a-personal-learning-environment/) which is composed of professionals and non-professionals in various fields including education and medical education. Sometimes what their tweets, blog posts, and articles go over my head. But I use this as an indication of how much more I need to learn and how rich the field of medical education is. It is hard to argue that language, or information, is used to keep people out of the loop in the Internet age. That’s why I think that a “tribe” is more than an acquired language. When I read vague terms, on twitter or blogs, I have tried to ask for clarification as they can have different interpretations. Terms in specific fields not only have a more defined meaning, but also also historical/level of expertise aspects attached to them. A Stanford aortic dissection means different things to a surgeon than it means to any other doctor. The same concept means different things to thoracic surgeons at different levels of expertise. Nonetheless, the information about the Stanford classification is in the internet for anyone to read/learn. The same goes for educational terms such constructivism, zone of proximal development, community of practice, and others.

            These terms have so much meaning behind them that trying to defragment them would destroy the concept/practice behind them. I am in no way saying that things need to be made complex, but rather that some things cannot be reduced further. I am also advocating for using the right terms under already established concepts. This, in my opinion, helps with connecting different fields and increase collaborative work. This should not be seen as a way to alienate other professionals involved in the training of physicians, but rather as a way to enhance interprofessional development and legitimization of the teaching profession in medical education.

            The points of implementation you bring up are very important to address. A descriptive/prescriptive curriculum is not as important, sometimes it might even be different from, as the curriculum lived by the learner and all others involved. This is why it is so important to have a good grasp of instructional strategies that increase the probabilities of learning at the institutional level. For example, the use of clickers can be used just to record answers to multiple choice questions. But if the teacher has a good grasp of constructivism clickers can be used enhance discussions in a classroom setting. Just using clickers does not imply the classroom exchange is a discussion, especially one that supports the theory of constructivism.

            One of the characteristics of theoretical frameworks is how applicable they may be in different times or space. Behaviorism is a great example and it has been used in education, business, and other fields (https://www.aliem.com/behaviorism-punishment-or-reward/). Although Lave and Wenger did not specifically write for online communities (that I am aware of), John Seely Brown has written extensively about communities of practices in online gaming communities. See video (https://www.youtube.com/watch?v=41pNX9-yNu4) If we view technology as another tool that belongs in a community practice we can discern its importance in a situated learning environment. I have written before how technology can help us with information management in medical education (https://www.aliem.com/learning-information-management-instead-of-evidence-based-medicine/) This in turn changes how we learn and how we make decisions in a medical environment. Vimla Patel has written extensively how the use of technology may affect our decision making. So, in my view, technology plays a crucial role in medical education and this role can be supported by the use of theories that hypothesize how we learn or make decisions.

            My arguments have not been against the use of technology, but about what instructional/learning strategies is augmented by the use of technology. Maybe that’s where the misunderstanding is. Technology for technology’s sake is a bad practice in my opinion.

            Thanks.

  • I agree with Anand. Most of the residents are already using multiple resources, and the ones that aren’t likely are familiar with them but choose not to. Even with FOAM champions in the department, there is still a lot of resistance from the old guard. Because a lot of the FOAM info is cutting edge, I frequently get flak at faculty meetings for “doing things that are against the books.”
    Part of the problem is the residents need to know what to answer for the board and ITE, but also need to know what is best for the patient. Sadly, these answers can be wildly different, and the old guard is fairly dogmatic about it. My poor residents are forced to use lidocaine without epi, sterile gloves, sterile irrigation, and antibiotics due to “the books.” Similarly, calcium and dig, not being able to use ketamine, etc.
    What we really need is a way to break dogma in the faculty, but they usually aren’t the ones who attend the lectures that address it.

    • Interesting insight. Are you saying that the first step in all this is to infiltrate and convert the faculty first as the first barrier to overcome?

      • Absolutely we need the faculty to be FOAMites. They’re the biggest resistance to incorporating more FOAM into the curriculum, no matter who produced the content.

  • Shannon McNamara

    Thanks for starting this discussion! There are some really insightful comments above about learner engagement, curriculum design, and didactic content delivery using FOAM.

    Q1 & Q2:

    As an EM resident learner, I found the #emconf feed on twitter to be tremendously useful. All of us learn within a specific institutional culture, and seeing dialogue and debate from programs around the US and internationally helped me appreciate other valuable perspectives in EM. It was fantastic to see a wide breadth of core knowledge reflected each week. This forum also encourages responsibility for our core knowledge, as programs will often respond to one another to debate a controversial topic.

    As an educator, I find that convincing learners to use Twitter can be a struggle. As Christopher Doty pointed out on Twitter, it can be “nerdy for many” and challenging to bring people to the conversation when they need to sign up for an account and learn the lingo. As Jeff pointed out about – learner engagement is key, and fraught with many challenges. As educators, we need to meet our learners where they’re at.

    We started the @TempleEM twitter account a few years ago, and I was surprised to sometimes find more engagement from users outside the institution and internationally. Sometimes it felt like we were reaching more EM docs in Saudi Arabia and Malaysia than in North Philadelphia. Now it seems like more faculty than residents have become more receptive to the platform, as they seem to be looking for more ways to stay current with medical news and literature. Temple responded to this issue by broadening the didactic approach to include FOAMed using a variety of modalities like podcasts and blogs to reach more learners, and to integrate digital education with the existing didactic curriculum.

    Time is another potential barrier for learners. Residents only have so much time to read, tweet, and listen to podcasts between working, eating, and sleeping. When incorporating FOAMed into the curriculum, it’s essential to focus on high yield, time-efficient resources that will engage learners without overwhelming them. Reading is still an important foundation, and can be augmented with other modalities, but we need to be cautious to give learners objectives that they can reasonably accomplish. Ideally, FOAMed can help with a flipped classroom approach, so that a small investment of learner preparation can lead to a more engaging, proactive learning environment during in-person didactic sessions. Finding that balance can be very challenging.

    Ultimately, FOAMed and social media have the potential to be tremendous assets for learners and educators in EM. Our ability to share quality content widely is a wonderful opportunity for learners. More importantly, FOAMed has created an international community of invested medical educators working together towards a common goal.

    The face of medical education is already changing dramatically. What remain to be established are best practices for using these new strategies through thoughtful discussions like this one.

    Thanks to everyone for your comments! I look forward to hearing more about different approaches to this issue.

  • Andrew Grock

    Mostly Q2 and some Q1

    Hello Everyone,
    Excellent post Dr. Haynes, Dr. Lin, and Dr. Kobner. Thanks for generating such a discussion about the key barriers towards FOAM implementation and thanks to the great commentators as well. I initially became involved in FOAM when I began writing for an evidence-based medicine blog series on my residency’s educational website (blog.clinicalmonster.com). I thought it was a great outlet for my love of education and allowed me to communicate the best of what I had been reading.
    The potential for FOAM as an educational tool in emergency medicine is incredible. At the same time, I agree with the comments above – especially the concern for quality-assurance in a non-peer reviewed setting. I wanted to find a way to improve the validity of FOAM while also finding a way to reward residents for using it as a learning tool. While many residents are using FOAM on their own already, I wanted to add in some sort of carrot to promote its use. Thanks to Dr. Eric Morley, Dr. Nikita Joshi, and Dr. Michelle Lin the idea for the Approved Instructional Resources (https://www.aliem.com/aliem-approved-instructional-resources-air-series/) has become an actual product.
    To combine curating FOAM resources and Individualized Interactive instruction, an executive board of respected EM educators uses an objective scoring system of our own design to judge a list of blog posts, podcasts, and videocasts. Our scale includes likert scale grading of the BEEM scale, Content Accuracy, Education Utility, Evidence-Based, Appropriately Referenced. After picking the top scoring 6-10 articles for each CORD Module topic, we write multiple choice questions and offer faculty interaction. Though this system, we create a list of peer-reviewed articles and enable residents to achieve credit for participating. We currently have 15 programs and counting using this series!

  • jeff riddell

    Q1: Agree with so much of what has been said. Some legit people on here. Something more to consider: One of the biggest barriers for educators is lack of evidence. Like Michelle said, do we like the shiny new toy because it is shiny and new, or because it works better. We need good prospective studies with sound methods to really make the case to the academy. Until we can show (and not just say) that tech/SoMe is better, appropriately skeptical minds will be reticent to adopt.

  • jeff riddell

    Q2: How do we engage learners? one way is to make sure we get credit for our time. The ALiEM AIR series (way to go Grock, et al) will hopefully help with this. Many in our program are regular consumers of podcasts, vodcasts, and blogs and we get little to no official “credit” for our hours of learning. The RRC has given us one hour, which is better than none. But it is burdensome to log all our SoME/tech consumption and time-consuming for program faculty to monitor that consumption. The easier it is for us to get “conference credit” for our time, the more engaged people will be.

  • jeff riddell

    Q3: Programs. I think the article did a bang up job of highlighting the great stuff going on. One thing to add. We (UCSF-Fresno) have a 30 minute case-based resident-led morning report every day at shift change. Last week we discussed a case of submassive PE. Due to all the recent Twitter and blog chatter about the PEITHO and MOPETT trials and the meta-analyses, we printed the papers for residents to read and had a discussion based on the commentary from EMLitofNote.com. We then presented an algorithm from EMCrit.com and discussed its utility. It was a fantastic integration, in the clinical setting, of social media and resident education. Would not have occurred without Twitter and the blogs.

  • David Marcus

    Excellent post! Thanks for spotlighting this paper on ALiEM. We’ve seen tremendous growth in the FOAM ecosystem over the past few years and pieces like this one are important in helping to spur discussion on the most effective use of open educational resources in EM education.

    The questions are thought provoking, and there’s not enough space to adequately address them all. Will try to touch on each (generations, rationale, #EMconf) based on my personal experience and readings over the last few years.

    Q1. Barriers to educators: #1 – Generational, #2 – Generational, #3 – Generational. Of course, educators face many barriers when implementing any new technique and I agree with all of the preceding comments. But FOAM, I think, is a special case. Comfort with technology, crowd sourced information, group think, and flattened hierarchy are all prerequisites. Our most senior educators are still primarily Boomers who have trouble with some of these. Gen-X-ers are now becoming more prominent in the educator landscape, but we too aren’t digital natives. Cellphones first came along when we were in high school or college and the Social Network was something that may not have appeared until medical school or even later. Our online “interactions” were made up of email and message boards. The Millenials (on whom too much has been written) have grown up in a networked environment that informs their values and social interactions. Their online experience started with Web 2.0 and for them the internet is an inherently social space. Thus we all have different expectations. Many senior educators consider the whole thing a waste of time while the new generation of educators sees the utility but hasn’t quite figured out how to reach the learners. The resulting situation is one in which junior educators are reverse mentoring their own mentors on something they don’t completely understand while trying to engage learners who can sense their uncertainty.

    Q2. Learner barriers are educator barriers, and there are many. Importantly, there has to be a reason for learners to use – and to trust – the technology. Why should they leave their comfort zone in favor of a new resource? Although the average learner is comfortable with technology, as has been previously noted, many choose not to use it. They don’t the see utility. And indeed, FOAM is likely not for everyone. It is another tool. Just another learning style to add to the VARK (eVARK?). Or perhaps it is yet one more strategy within each of the VARK categories (there are FOAM examples for each: Visual, Aural, Read/Write, Kinesthetic). At our institution we have been trying to make the case that FOAM is an excellent way to stay current and to engage colleagues and thought leaders, a gateway into reflective practice, a critical tool for “lifelong learning”, and a place to find answers “on the fly” (as is often needed in EM). We start with an introductory session in Intern Orientation that leads into a recurring “asynchronous learning” module. It is essential that learners use “good” resources and one of our goals is to help residents learn to sort it all out. To this end we regularly spotlight reliable resources and new items from various blogs, podcasts, and other media. Experiential learning, as mentioned, is crucial and we hope to move forward with content generation by our residents and faculty. It is true that “if you build it they won’t necessarily come,” but if you give them a good reason to be there, they’ll probably stop by.

    Q3. Although mentioned in the Scott et al paper, I would like to highlight the #EMconf project. It’s been a year since we threw this hashtag into the FOAM ecosystem. Our idea was simple – to create a common space for Emergency Medicine training programs from around the globe to share their teaching. After all, we all learn essentially the same thing, but in different ways. Why shouldn’t we compare notes? Live conference tweeting was already well established, and this seemed to be a natural extension of that pastime into the EM classroom. Many people were involved in the initial discussions, including Jeremy Faust, Nikita Joshi, Seth Trueger, Natalie May, Mike Cadogan and others. We all felt this tag could lead to some interesting conversations, but weren’t sure if it would take. Since July 2013 #EMconf has become a regular feature on Twitter every Tuesday, Wednesday and Thursday. Training programs in the US, Canada, South Africa, Italy, and Great Britain share pearls, images, discussion and humor from their lecture/conference series on a weekly basis. Just last week more than 900 #EMconf tweets by 200 people led to approximately 460,000 impressions. Where there was once learning in isolation with minimal external validation there is now a lively community in which trainees and faculty at one training program can impact discussions at another program hundreds, or even thousands of miles away. Students, residents, registrars, fellows and other trainees can now participate in their own program’s didactics – or in those run by another program – if they happen to be sick, out of town, sitting on a beach somewhere, or even at work (if it’s quiet…). And, by following longitudinally, users compare their own practices with those that are taught at sites around the world while reaping the benefits of spaced repetition. Of course, none of this would happen without voluntary participation by faculty and trainees. This is one of the key limitations of any hashtag – it is only as useful as the need it addresses. The conversation needs to be worth having. Fortunately, there seem to be many people who want to spread the word about their programs and the amazing things they are learning, and there are many others who want to learn and critique. To see a full list of EM, IM and EM/IM+EM/FM programs on Twitter, check out the list presented by Salim Rezaie on ALiEM: http://bit.ly/1u1Uuum

    FOAM is still in its wild-west phase, but it may be settling down with the adoption of more robust review processes and a growing acceptance of its utility in formal EM training. Hopefully it won’t settle down too much, since the free-for-all nature of FOAM is part of its beauty. And yet, despite the ruckus, only a small fraction of Emergency medical practitioners actually participate in discussions (though many seem to use materials generated). As the next generations move into academic leadership positions I am hopeful that we will continue to see broader adoption leading to new, more productive, ways of using open educational resources in EM training.

  • Sean M. Fox

    At Carolinas Medical Center we utilize Twitter to participate with #EMConf.
    In addition, we publish what we call “Carolinas Core Concepts,” which are the main teaching points from presentations, to our website http://www.cmcedmasters.com/core-concepts

    Also, many of my residents utilize other FOAM resources, which they can access from http://www.cmcedmasters.com/foamed.html

    Essentially, we have made a very useful and interactive website (www.cmcedmasters.com) that houses a ton of material that the residents use every day during shifts and at home. Since some of the material is institution specific and sensitive, certain areas of the site are password protected.

    Also, I send the PedEMMorsels (http://pedemmorsels.com/) out to everyone every Friday. The residents and students can easily reference them during shifts via the website or receive them via twitter, linkedin, G+, email, etc.

    Regarding Q1: The biggest barrier is TIME! The time that is required to generate content can be significant. The time that is required to maintain a website can be considerable. Fortunately, I have awesome residents that are very involved in the improvement of the cmcedmasters.com site.

    Additionally, another significant barrier is the learning curve and grind of FOAM publication. Needing to have stamina and perseverance as your learn the craft of generating quality materials can end the endeavor before it gets off the ground (not everyone is a Michelle Lin from the beginning).

    Thank you all for your awesome leadership!
    -sean

  • Brian Adkins

    Q2: In our emergency medicine residency program at the University of Kentucky, we have multiple faculty members participating in the use of twitter for educational purposes.
    Matt Dawson is active through the Ultrasound Podcast and Andy Sloas through
    PEMED. Chris Doty is “live-tweeting” our educational conferences and
    it allows even those of us who are not present to participate.



    My primary social media teaching experiences are at the undergraduate medical level. I am
    co-course director of the Introduction to Clinical Medicine 2, a course that
    involves a lecture series, clinical skills and ultrasound workshops, and a
    preceptorship that exposes the students to evaluating “real”
    patients. Over the last two years, I have built a fairly popular social media
    presence within the class for both communication and evaluation. We have
    a Facebook page for sharing questions, ideas, and links to pertinent clinical
    videos and heart and breath sound simulators. Most importantly, I have a
    weekly twitter bonus quiz on Wednesday afternoons. Each week, I tweet out
    a clinical case of under 140 characters with an associated physical exam image.
    The students reply their answers to me privately through direct message
    and the application keeps the answers in order of receipt. The first
    twenty correct respondents get a tiered level of bonus points toward the next
    exam. Following twenty correct answers, I will cash in on their attention
    by tweeting the correct answer with a link to medscape article on the illness
    or exam finding. After the teaching point is digested comes the students’
    favorite part: the announcement of the winners. I declare the winning
    student the “twitter champion of the world” by announcing their name
    and posting a picture of a championship belt. I typically then announce
    the top ten and twenty who will be receiving bonus points. Finally, in an
    effort to encourage fun and socialization on the feed, I reward the student
    with the most clever or comedic response with the “Humor Heisman”.
    This student’s name is announced with a picture of the Heisman trophy.

    Honestly, it has been a tremendous amount of fun for me and the students. They literally sit with their smartphones hitting refresh at 1:15 every Wednesday afternoon trying to
    be the “Twitter Champion of the World” and earn bonus points.
    The activity is completely voluntary and I have over 90 of the 116
    students following me on my twitter and usually about 40 heavily participating
    in the responses each week. Their active participation has allowed me to get
    know several of them in an informal atmosphere and I can reach them with other
    educational tweets along the way. The “Humor Heisman” has
    become it’s own competition as well and it has brought out the best in comedy
    from the crowd. At the end of the year, the students with the highest
    point totals for correct answers and Humor Heismans each received a faux world
    championship belt and restaurant gift cards in front of the entire class at a
    ceremony. I would encourage use of social media in the undergraduate
    curriculum for the obvious educational benefits and camaraderie it has provided me
    with my second year students.

    • Wow, this a great example of an engaging, effective, and humrous way to incorporate social media (Twitter) into medical education. It’s has a low barrier for potentially new Twitter users to join in the conversation and see the value of it. That’s really the first important step. Thanks for sharing these great photos!

  • Tamara Moores

    Q2. Engage the Learners:

    I am a third year resident at the University of Utah. Our program has been so very excited about incorporating as much FOAM as possible. A few examples:

    1. We provide iPads to all of our interns. In the first few weeks of residency we have a tech day, where I and our PD sit down and help our interns download textbooks, RSS feed readers, twitter, subscribe to our internal shared evernote conference summaries folder, and install helpful apps. Once we show them how easy it is, they are engaged in this system, and they simply continue to use it throughout their residency.
    2. We make conference quick-reference summaries, and distribute them via evernote, similar to paucis verbis. Our conference lecture summaries automatically upload to our resident’s smart devices, so that they can reference recent conference information on their very next shift.
    3. We require asynchronous learning to occur in each subject block of conference. This involves assigning a podcast to the group, then bring in local experts on the subject and have discussions between them and our residents during conference.

    As a resident in this program, I can’t say enough about how exciting it is to learn in this fashion. I feel incredibly lucky to be at Utah.

    • Wow, Tamara. Thanks for sharing your program’s efforts to bring asynchronous digital material into the curriculum and day-to-day practice. I too find that evernote is amazing for education, and often underutilized. Keep up the great work!