MEdIC Series | The Case of the Catastrophic Classroom – #CORDaa16 Edition

2016-12-14T18:44:24+00:00

This ALiEM MEdIC series is part of a very special event! In a few days in Nashville, TN the ALiEM Design Fellows (Dr. Catherine Patocka & Dr. Jeremy Voros) and I will be joining forces with CORD’s Dr. Rob Cooney to organize a special Design Thinking Hackathon. This workshop will take place at CORD’s 2016 Academic Assembly, which is only a few days away.  We are very excited that our Design fellows team will be helping to introduce people to the world of Design Thinking!

During our session we will be challenging a group Emergency Medicine educators from all across the nation to rethink their local residency conference (#EMConf). But we need YOUR help! And we’re asking it via the ALiEM MEdIC series through the Case of the Catastrophic Classroom.

We’re hoping that you can help us uncover facets of a problem facing all of us each week:

How can we make our classroom/academic time truly count for our residents?

Take a look at the following case, and let us know what problems you think that you see in our case, but also share the problems you have encountered with the residency academic programs you remember (or are currently experiencing).

The Case of the Catastrophic Classroom

By Drs. Catherine Patocka (@PatockaEM), Jeremy Voros (@VorosMD), Robert Cooney (@EMEducation)

Jill, an emergency physician, is a recently-hired junior faculty member at the St. Elsewhere Emergency Medicine (EM) residency program. She completed her own training 5 years ago at a well-respected residency, where she was chief resident, and then stayed on as a faculty member. She had a strong interest in resident education and was active on the CORD listserv. But there was a well-established leadership team at her home program and limited opportunity for advancement.

Jill took a position at St. Elsewhere, a less-established residency, that offered her a leadership role. Her first challenge in this new role was a revamp of their weekly half-day educational conference.

This is how the St. Elsewhere residency program’s informational web page described about their conference:

“Our residents are relieved from regular hospital duties (i.e. they receive protected time) to attend conference. The sessions are held in a Campbell-Morrison memorial lecture hall at St. Elsewhere every Wednesday from 7:30 am to 12:30 pm for their educational conference. The day begins with a Morbidity and Mortality conference, followed by various lectures delivered by senior residents or faculty members. Lecture topics are on a repeating curriculum on a 1.5-year cycle, thereby ensuring that the residents see every topic as both a junior and senior resident. Our curriculum is based on the EM Model and uses guided readings from prominent EM textbooks.”

When Jill emailed the current program director (PD) about who the last curriculum lead was within the faculty, and how s/he designed the curriculum. The PD quickly wrote back stating that he couldn’t remember, and that he thinks it was always that way. He wrote: “I think this is the way things are done because this is the way things have always been done.

 

Jill’s First St. Elsewhere’s EM Conference Experience

Jill arrived early and sat in the back of the hall taking notes throughout the first conference. She was joined in the back of the lecture hall by a rotating cast of 3-4 faculty members who came and went throughout the conference. Only one other faculty member attended the whole conference but he worked on his laptop the whole time.

The Morbidity & Mortality (M&M) conference was a series of typical case presentations lead by a senior resident. The resident involved in the management of the case stood before the group as well, answering questions about his thought process and management choice. Several residents took questions clearly placing blame on their choices, and one of the residents became quite tearful and had to leave the podium mid-presentation.

A 4-question multiple choice quiz followed M&M, about the week’s assigned reading. Residents perfunctorily completed the quiz. Correct answers were provided by the residency coordinator afterward. No discussion followed.

M&M was followed by several PowerPoint-driven, didactic lectures. One was given by a senior resident, and included a detailed review of the Kreb’s Cycle. Another was given by a faculty member on renal emergencies but the slide deck was clearly prepared by someone else, as evidenced by the fact that the other person’s name was still listed on the title slide.

Throughout the conference most residents were slumped in their chairs staring at their smartphones. One resident slept in the front row.

There was confusion over which faculty member was supposed to deliver the final lecture and the assigned person was not present or reachable by phone. As such, the conference ended 45 minutes early.

 

Jill Meets with the Stakeholders

Jill met with one of the chief residents, Rob, to discuss conference. Rob is well-respected among the residents and besides being clinically excellent is a reliable advocate with the administration. He expressed frustration about conference. The format is largely unchanged from when he was an intern. He feels too much of the teaching is done by senior residents – which though beneficial for junior residents, leaves senior residents’ needs unfulfilled. Early on he had hoped to stay at the program when he graduated but now he is actively looking for an academic position elsewhere.

Jill heard more complaints from faculty after their last staff meeting. Several staff members complained that there was no CME credit for them if they attended. One faculty member, who had previously been a regular presenter at conference, complained about the lack of financial incentive (i.e. “There is no buy-down! It’s essentially volunteer work!”) or even recognition throughout the residency for active involvement in the educational conference (“I don’t even get a thank-you letter!”). Others complained that the early start time made coordinating childcare difficult. Some expressed surprise to learn of any concern over the quality of conference.

Jill also met with the program director, Ravi. He has been in the position for 5 years. Two of those years were complicated by conditional accreditation by the ACGME. When asked about conference he became exasperated. His primary goal is to stick to the ACGME requirements, especially those concerning total conference time and faculty supervision. He acknowledges his focus has been on duty hour compliance and implementing resident assessment based on the new milestones, rather than educational innovation.

 

Jill Seeks Advice

Jill reached out to her colleagues on the various listservs for suggestions to reinvigorate St. Elsewhere’s educational conference. Many users suggested a “flipped classroom” approach but each had different conceptions of the final product. Some recommended FOAM resources on the internet, but others expressed concern about ACGME compliance. Other popular suggestions included small group sessions, off-site learning, and self-directed study.

Key Questions

  1. What problems have you encountered in your EM Conference / Academic Day proceedings?
  2. What are problems that you can identify in the above case? Are there any specific problems that resonate with you?
  3. What are some solutions you have encountered or seen with regards to rejuvenating academic proceedings for residency programs?

Weekly Wrap-Up

This month, we will actually be opening up our weekly wrap-up to our hack-a-thon participants. We hope to post some of the solutions that the #CORDAA16 Hack-a-thon will generate for this case. This means that there will be a short delay in the wrap-up this month, and we will aim to post these insights within a few weeks of our initial discussion.

Additionally, Robert Cooney and Teresa Chan will author a blog post that summarizes the process we used to generate these cases.

On March 18, we will plan to post the Expert Responses and Curated Community Commentary for this case. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary, which was released on that date. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • Anand Swaminathan

    I’m having flashbacks to when I took over conference creation duties 5 years ago. This is an oft faced problem with numerous ways to go about solving. The approach you take is going to depend greatly on the system and support you have in place.

    There are two solutions that people readily fall back on that are equally dangerous and should be avoided:
    1. Raise the level of conference on your own. Give great talks every week, lead discussions and workshops. The obvious danger here is that you will be overwhelmed and burn out rapidly. The less obvious danger is that other faculty will quietly (and not so quietly) begin to loathe you as the residents will become “mini-yous.”
    2. Leave it as it is and walk away, after all, it worked in the past.

    Let me address the questions you listed above because they are an excellent place to start

    1. What problems have you encountered in your EM Conference / Academic Day proceedings?
    – Rote recitation of textbook materials
    – Hour long lectures covering textbook chapters
    – Lack of faculty involvement (no reimbursement, extra time etc)
    – Unclear faculty responsibilities
    – Educator centered learning (as opposed to learner centered)

    What are problems that you can identify in the above case? Are there any specific problems that resonate with you?
    – It is typical for faculty to be oblivious to the deficiencies of conference, particularly if they don’t see any need to go and attend.
    – Support for the conference organizer and support for faculty who are giving their time

    What are some solutions you have encountered or seen with regards to rejuvenating academic proceedings for residency programs?
    – The most important thing I’ve found is support from your PD and chair. Your PD has to support the changes you want to make (in this case I would blow up the entire format and start from scratch) and your chair has to support your need for faculty commitment
    – Create (with your chair and PD) core faculty requirements for conference involvement. Again, your chair must be clear – if you don’t want to teach, feel free to pursue a job somewhere else or take on more clinical hours.
    – Have faculty assigned to conferences. Many residency programs do this. 2-3 faculty are assigned to conference and are expected to help with whatever is needed (facilitating workshops, group discussions, occasionally giving lectures). Even better, have faculty assigned to an entire module or block (4 weeks). Empower the faculty by allowing them to select areas of their interest to be involved in.
    – Accountability (also comes from the chair) for faculty and residents
    – With this support, you can move forward with adding more small group sessions and workshops where the residents are more engaged.
    – Empower learners – ask the residents how they want to be taught, how they want to learn
    – Listen to the faculty – put resident talks early in the day so that faculty don’t have to worry about child care issues. Highlight M+M in the middle of the day since it tends to bring in more faculty (everyone loves to stare at an accident).

    These are just some of the things I worked through over the last 5 years and continue to push for. This isn’t an easy process or a quick one. It takes years and years to shape your conference into something you’re proud of. I’ve been working on it for 5 years now and I’ll let you all know when I’m happy with the final product.

    • Awesome of you to share your thoughts and wisdom Swami.
      Are there any particular problems you have encountered over time that are worth tackling especially?

      • Anand Swaminathan

        Many of things I mentioned already. The major thing is getting buy in from the higher ups in your department and their support. Without it, you can’t get the faculty to do what’s needed because you’re not in charge of them.

        • Yes, I agree… Buy in by higher ups is important.
          Any tips on getting them on your side?

  • Jordan Spector

    Love this thread, very excited to read and learn from others’ comments and replies – I think anybody who has helped coordinate and manage a residency curriculum can relate to the subject case at St. Elsewhere. Having coordinated and managed the residency didactics at two separate programs, I have seen a couple of different models in action, and I’ve made A LOT of different mistakes. I was certainly guilty of Anand’s dangerous solution number 1 – biting off significantly more than I could chew by creating and scheduling myself for a multi-part full physical exam lecture series, while also trashing and remodeling the journal club paradigm, all the while trying to oversee and manage the entire curriculum. The flaming candle wicks at the top and bottom definitely burned all the way through with that approach!

    Having done this for a few years, I am only now understanding the delicate balance that has be achieved, that can easily overshoot in one direction or another without careful oversight.
    –For example, I have found that lectures are significantly better when a speaker (resident or attending) has strong input on their topic and content….and yet the conference creator must make some attempt to provide a comprehensive curriculum, to be sure their learners receive some key elements in the ACEP Model of Clinical Practice – and who wants to give the rheum lecture anyway?!?
    –For example, I have found the compulsory attending presence at conference does increase turn-out (one of my sites had assigned faculty on every lecture date), but those faculty were much more likely to show up late, sit in the back of the room with the laptop, and then grumble at what they perceived to be undue burdens on their time, unrewarded efforts for the group.
    –For example, we have tried hard to recruit more faculty, visiting EM and/or non-EM specialists to provide content – to address and assuage resident perception that they themselves provide the lion’s share of the lecture content. And not infrequently, we find the recruited pediatrician or cardiologists or whoever are unfamiliar with the current climate in EM education – giving talks that lean heavily on verbiage-dense powerpoints, not looking up from their anchored position at the podium.

    For the sake of not going all ‘Herman Melville’ with a 10,000 word post here, I will just hit on key question #3 “What are some solutions you have encountered or seen with regards to rejuvenating academic proceedings for residency programs?
    –We have a ‘Conference Improvement Committee’, residents and education division faculty who meet once or twice year. Last year they created, distributed and collated a ‘Survey Monkey’ on conference – which regular topics work, which need to be revamped, etc. Perceived ownership of the curriculum increases perceived value, IMO.
    –Small group sessions – the more, the better. The first iteration of this in my current shop has been tremendously well received – it includes multiple simultaneous sessions in our sim center, a sim case, a group discussion, a procedural training exercise, all running at the same time, residents rotating through all of the stations. It makes for an outstanding learning exercise when done well, but it is very heavy lifting – coordinating simulation resources, finding teachers who are willing to provide the same lesson multiple times in a row, etc.
    –Just turning off the projector – if someone is to give a lecture on UGIB for example, break the room into 4 groups – have one group read a seminal reference on the topic, one read the AHRQ data on the topic, have one group sift through Tint’s, then they can sequentially go around the room and teach one another. My early efforts at flipping the classroom were short-circuited when I realized none of the learners put in the time to prepare in advance, with shift-work, and life, etc. This model obviates the need to prep in advance.
    –Obviously the residents have the ‘stick’ that is the ACGME-mandated 70% attendance……have any of you offered the carrot to residents who are above that number? Regarding faculty, one could argue that the Chair and/or PD should use the carrot/stick for faculty participation, but I have yet to see either of those employed.

    Thanks for posting Teresa

    • Love the idea of the Improvement Committee!! Active PDSA of educational programming is a great idea!!

      What are your thoughts of harnessing social networks / constructivism / group accountability to create a culture of attendance (rather than relying on on carrots and sticks?

      • Jordan Spector

        I am really fortunate at my present site that there is a core group of faculty, many senior, who prioritize conference attendance and participation, establishing a strong example for all of us. ….my current residents don’t know how good they have it!!!…This constructivism was here well before I took on this role last year…I agree that such a culture of attendance improves morale and helps learners derive meaning in ways that carrots/sticks likely cannot. Again, im lucky, but I have struggled in the past trying to harness accountability – enthusiastic pleas to peers at a faculty meeting didn’t really do it. I’m Interested how others have addressed this.

        • Yes. I have been to many sites where a strong local culture creates this obligation to be at Rounds (NYU Bellevue is an example, Queen’s University in Kingston, ON is another). At our site, one of the challenges is the vast geography that exists. Our faculty are affiliated under one university, but all the teaching tends to happen primarily at one site. Also, many of the physicians live in neighbouring cities… due to distance, parking costs and other logistical reasons, it can be hard to get people to come out.

          I wonder if it is possible to flip things around…

    • Jeremy Voros

      What methods have helped lighten the heavy lifting of small group sessions?

      • Jordan Spector

        I think spreading the wealth has helped, we don’t really ask our faculty to run a (thrice-repeated) session more than once a year, or so. We have brought in ENT folks to teach NPL, we have brought in PT/OT folks to teach a comprehensive knee exam, etc. Call the session something fancy for your consultants and couch it as a CV bump. We also have a PGY4 as an “Education Chief” of sorts, who participates heavily in small groups planning; (s)he can engage peers about ideal content, foster the sense of ownership that we have referenced in this thread. And (I have a hunch) that some faculty are more likely to perceive a ‘greater good’ when a resident asks for faculty help with the curriculum, rather than the perception of ‘unrewarded effort’ when a colleague asks

        • Robert Cooney

          That’s a great point. As an educator, it’s tough to turn down a learner who specifically asks for help! How do you structure your small groups from an annual perspective (the curriculum) and from a “day of” perspective?

  • Resident conference is incredibly important, and if it stinks, it HAS to be fixed. The issue is one of stagnation. Many places simply don’t ever go back and reexamine what is working and what isn’t. Producing an excellent conference experience takes a team of dedicated educators. At The University of Kentucky we have EXCELLENT folks who truly care about the quality of the experience: Jon Bronner, Chris Doty, Farhad Aziz (will be a medical education fellow with us next year), and a few others. You need a team to create an excellent experience. A team that cares and is always willing to try new stuff to see what works best.

    1. What problems have you encountered in your EM Conference / Academic Day proceedings?

    -Boring Power Point lectures (becoming more and more uncommon)
    -Lectures too long
    -Difficulty getting faculty to speak in conference (and change the way they deliver educational material)

    2. What are problems that you can identify in the above case? Are there any specific problems that resonate with you?

    I think the main issue is stagnation. There is nothing worse in education. We now know more than enough from the med ed and cognitive psychology literature to create a truly great learning experience for students and residents.

    Stagnation is the enemy.

    3. What are some solutions you have encountered or seen with regards to rejuvenating academic proceedings for residency programs?

    In order to rejuvenate an educational conference day you have to be willing to take risks. Having said that, I think we know what works and what doesn’t. Power Point talks, in my opinion, for the most part suck. And suck badly. Get rid of them. Interactivity is the key. You can always assess learners to see what they like, but get rid of lectures. They are dinosaurs looking for a tar pit. Find ways to engage the audience of learners. Ask people in other programs what they did to resuscitate their conference.

    Ask the simple questions: What needs to change? What sucks? What is working? Who is on my team to make these changes happen. And…do I have buy in from the Chair/Program Director?

    If you truly want to change conference you are likely going to need to engage in some pretty substantial faculty development for the folks who teach in conference. For example, we started using iSimulate to teach simulation and case management in conference. There is a learning curve with iSimulate, so faculty who want to use it have to learn how to implement it during their sessions. And be careful of technology. This might scare some of the older faculty and prevent them from wanting to get involved.

    Technology is not necessarily the solution. A conference grounded in solid learning principles is the solution. If you are tackling revamping conference you MUST did in and learn more about how adults learn best. Plenty of great books on the topic.

    • I like the idea of thinking of tech NOT as a solution. I agree, conference should be grounded in solid learning… What are some great books that you can recommend Rob?

      • Best book I have ever read on learning is “Make it Stick.” If you develop a conference strategy based on sound learning principles you will be successful. That’s exactly why many conferences aren’t good. They don’t teach the way we all learn.

        • Thanks Rob!

          • This book is absolutely the best one I have ever read on learning. It’s incredible.

  • Loice Swisher

    I love this case as I think many programs are struggling with this. Although it doesn’t help the lion’s share of the issues shown for in-person conferences (residents on cell phones, lack of faculty attendance, poor interaction, absent innovation), I am particularly interested in independent individualized instruction (asynchronous learning).

    Our program uses lectures from regional and national conferences with a quiz at the end. I believe this gives the residents exposure to some of the best teachers/lectures EM has to offer as well as assists with a habit of life long learning (as the format can be continued for CME as an attending). The resident can chose to do this at a time when they are most able to pay attention (and can rewind if their mind took a road trip.) The AliEM AIR series is another venue which introduces residents to some of the best FOAM out there.

    I wholeheartedly agree that those at the top have to value resident education- perhaps using both the carrot and the stick. Without the top making it important success may be elusive.

    Do folks think it is possible for residents to pick a list of 3 items that they really would want to change and then have the faculty agree on which one of those that together they would focus on re-inventing? In this way there can be resident and faculty buy-in without trashing the entire schedule which can over-extend and overwhelm everyone.

    • Jeremy Voros

      How do you balance the benefits of asynchronous, national content with the ACGME accreditation requirements?

      • For the non-Americans, Dr. Voros, can you explain what you mean by ACGME accreditaton requirements?

        • Robert Cooney

          Hope this helps!

          Per the ACGME EM FAQs (http://www.acgme.org/acgmeweb/portals/0/pdfs/faq/110_emergency_medicine_faqs_07012013.pdf):

          What types of experiences do NOT count as didactic experiences?

          “Daily” experiences, such as morning report or change of shift teaching, in which not all residents are consistently present and which are informal, do not meet requirements to be included as part of the five hours of didactic experience per week, due to quality and availability concerns.

          What are some suggested formats or methodologies programs may use for planned didactic experiences?

          Recommendations for the majority of educational activities include: small-group techniques, such as break-out groups, serially repeated conference sessions, or practicum sessions; or large-group planned educational activities.

          How much individualized interaction instruction is acceptable and what qualifies?

          Programs may utilize individualized interactive instruction for up to 20 percent of the planned educational experiences or didactics (i.e., on average, one hour out of the five hours per week of planned educational activity).

          The goal of individualized interactive instruction is to give program directors the ability to adjust curricular needs to the individual needs of each of their residents. It is important to note that simply reading or answering questions does not meet the requirements for planned educational activities.

          In order for an activity to qualify as individualized interactive instruction, the following four criteria must be met:

          1. The program director must monitor resident participation.
          2. There must be an evaluation component.
          3. There must be faculty oversight.
          4. The activity must be monitored for effectiveness.

          Examples of individualized interactive instruction might include:

          • A resident prepares for and takes a quiz or test, and receives timely feedback about his or her performance from a faculty member.
          • A resident spends additional time in the simulation lab or cadaver/animal lab because he or she needs more practice with a certain procedure.
          • Residents who are doing poorly on quizzes/tests participate in board review study sessions with colleagues or faculty members.

          Attestation and completion pages are not acceptable to the Review Committee as evaluation. Use of audio, video, or podcasts alone constitutes passive learning and is not considered interactive learning. Proprietary systems, such as PolyCom or Skype, that allow for real-time questions and answers, do qualify as active/interactive participation.

          How does the Review Committee document resident attendance at 70 percent of the planned emergency medicine didactic experiences?

          Verification is cross-checked by reviewing an eight-week conference block and averaging resident attendance for that eight-week period.

  • jeff riddell

    Thank you for highlighting this important topic! I’m eager to see what the design hack-a-thon at CORD folks come up with.

    1, 2: Problems:

    -Faculty attendance can be abysmal. It makes a huge difference to have faculty comments at the end of a PGY-2 lecture. The faculty debate may be the most important thing for senior residents to hear.

    -Minimal active learning. We have both theory and data to show that active learning is probably better than traditional lectures. Yet we persist with traditional hour-long PowerPoint lectures.

    -Hard to make content relevant to 4 different years of learners. We don’t give the same lecture to 4th graders that we give to 7th graders, yet we give PGY1 and PGY 4 the same material. Not very efficient.

    -Attendance requirements are not competency based. It doesn’t matter if you’re a brilliant PGY-4 resident who does great clinically and on exams – you still have to attend the same percentage of conference as a struggling intern. Seems terribly inefficient to me. Further, conference attendance does not correlate with in-training exam scores (Hern 2009) – what are we learning at conference?

    -Faculty are not incentivized to teach well. There is often little to motivate them to change. Why wouldn’t a busy faculty just keep reading from the slides that they made 5 years ago? Very few carrots or sticks.

    -Residents (and faculty) don’t pay attention. There was an abstract at an OB-GYN conference last year that tracked resident attention in academic half days and at their best, residents were zoned out for 25% of lectures. That’s 1 hour out of 4 (at best) that residents weren’t paying attention.

    -Scheduling. You’re by definition teaching adults when the program specifies it is time to learn. Post-night shift, before a long shift, during your busy ICU rotation, after a devastating case has shaken you. These are times when residents aren’t going to be the most receptive to what is going on, yet we force them to “learn” at these times.

    3: Solutions:
    I defer to people like Swami and Rob who have been doing this a lot longer than I have. The CORD Hack-a-thon people will also be brilliant. But I’ll offer a few suggestions. The ACGME would have to change requirements to fix some of the above problems (competency based, less time requirement, more freedom to incorporate what the residents are actually using to study: social media). And, as Swami said, a local chair would have to incentivize to change others.

    Something to work into the mix would be core content lectures can be delivered in 15-20 minutes (keeps attention) followed by break-out discussions stratified by year. So the 4’s can discuss current papers while the interns discuss the diagnostic approach. Seems more germane to specific learners. Though I haven’t experienced it, I have a hunch that letting learners loose to look up and explore clinical questions leads to a host of positive outcomes.
    Oh, and having breakfast/coffee also makes a difference.

  • Aaron Brown

    This is a very timely topic for me. We are in the midst of residency changes and in the process I have been tasked with the improvement of our resident didactics and other curriculum. I have to admit that it is hard to know where to start. As stated by others, it is not possible to do it all yourself. Others here have done a nice job highlighting the issues from this case and I find them all eerily familiar. As someone at the beginning of the process similar to the faculty member in the case I wanted to share a few thoughts.
    1) Beg and borrow content from others but make it your own. That is the beauty of CORD and other forums such as this. You cannot concentrate on re-organization and innovative/interactive delivery of the content if you are spending all your time creating it. It is not feasible as others have said. In this case study, the faculty member should look at her old program and borrow aspects that made their conference great. It is fine for faculty to use education materials created by others but they should take teaching ownership and tailor the delivery/content.
    2) Team work. This is too big of a job for a PD and even for any one other person. It will takes a village to raise residents, so start cultivating that leadership team and core faculty group. I am very excited about our program’s team. It has already fostered new ideas (similar to those seen in forums such as this), creates infectious energy, excitement, and support when you need it most.
    3) As others have said, use the residents for help. We unfortunately quickly forget what is was like and the audience’s needs. When involved in a constructive manner rather than a destructive manner residents will have ownership and less complaints. That being said they should not just be tasked with a topic as that will be a failure for all (teacher and learners). The focus should be on mentorship in the delivery and creation of the materials with key learning points and not necessarily covering all the content. Learning will follow.
    4) Faculty incentive is difficult. I can say we have tried various “carrots” over the years for individual efforts will limited success. However, it has not been tied to quality and only to participation. I think the key is to have buy in from a invested core group with a truly meaningful incentive rather than diffuse it across too many to make it meaningless.

    • Hi Aaron:
      Do you have other techniques you are considering aside from didactics?
      Also, what format are you using for your didactic lectures? How long, etc..?

      Finally – why do you think that “We unfortunately quickly forget what is was like and the audience’s needs.” How can we increase our empathy for our learners?

      • Aaron Brown

        Teresa,
        1) For other techniques, I wish I had a better answer, but to be honest I think we are a little behind the curve and that is one of the reasons for my new duties. We do use simulation for the interns to introduce the management of common medical emergencies. We use higher level sim cases to work on the management of multiple patients at once, resource utilization, and to broaden the differential of our upper year residents (those rare diagnoses that are not well remembered/enforced in lecture). We do other procedure labs and small group sessions for many topics but not much for core content. This is a work in process. I do a lot of synchronous module work with Articulate for my medical school course (Evidence Base Medicine) and we have only 1 lecture for the whole course and otherwise 15 modules with integrated quizzes and small groups. I hope to bring some of that to the resident education. We currently have only Articulate resident EKG modules. I would love to say the resident are huge fans of the modules but it hard with limited time to make them as entertaining as they would like.
        2) Our lectures are still mostly an hour but our team is in agreement that is not the best. We will likely cut some of them down to about 30 minutes and make sure there is time between topics. The worst is when one topic runs over into the next with little break. More small groups is needed for sure.
        3) I am not truly sure why we forget so fast. We often forget to start with the audience and their needs and focus on the topic first. Maybe this is faculty education issue but I think we focus only on our topic and forget about the other 3-4 hours the audience will be sitting through.
        I do think we also usually over estimate how much they know because clinical performance is very different from knowledge, and we do not do a great job of assessing their knowledge in real time prior to our teaching efforts. If we did that before each session, I think we could better tailor our efforts. In addition, many of us rarely sit through 4 hours of continuous lecture anymore ourselves. It is torture! I don’t blame them for having trouble paying attention.

  • Alex Chorley

    I think this an excellent case as these are common problems in many EM programs across North America. I decided to centre my medical education fellowship project around renewing our EM Conference and it’s been a very rewarding (but challenging!) experience.

    1) Some of the problems we’ve encountered:
    -Long lectures that end up being a regurgitation of a textbook chapter
    -Falling engagement from the faculty and residents
    -Difficulty finding space for new subjects

    2) Problems from the case that resonated with me:
    -How to engage faculty who are already incredibly busy with clinical and non-clinical responsibilities
    -How to deliver more engaging/relevant content

    3) Some solutions I’ve seen:
    Delivering engaging content is always going to be a challenge when residents and staff are busy and tired at baseline. What’s worked well recently in our program is a new approach to our toxicology block involving a flipped-classroom/small group technique. A staff member collaborated with a few other schools to create summary videos for different topics in toxicology followed by short quizzes. At our conference we then got together in small groups (mixed with different PGYs in each) with one faculty to facilitate. Covering set questions and cases as a group AFTER we had done the required reading led to some excellent discussion with the senior residents acting as role models for juniors and the faculty providing expert guidance when necessary. This was also helpful for getting faculty engaged since it required much less prep-time than giving a full lecture.

    Another technique to improve learning/engagement that’s worked quite well has been the pre/post-quiz. At a recent lecture, another senior resident gave a short-answer quiz on the subject she was teaching about. Residents answered it as best they could and then we took up the answers throughout the lecture. At the end of the lecture we flipped the page and repeated the same quiz but with obviously better results! This immediate recall kept people engaged throughout and also helped with retention of the information.

    I’m looking forward to hearing about everyone else’s solutions!

    Alex

    • Jordan Spector

      The videos as a basis for small group discussions sounds appealing, everybody loves screen time! Anything you can share with the collective? How did you encourage/ensure a sufficient number of your learners completed the required reading prior to the session?

      • Alex Chorley

        I can put you in touch with the staff who is leading the project if you’re interested in the Tox curriculum. The videos were hosted on a university site that tracks completion of video watching as well as the quizzes so it was easy to see who had actually done the homework. The real encouragement though was participation in the small groups; if you didn’t do the work it was pretty evident during group discussion.

  • Will Sanderson

    A lot of really great stuff already mentioned above. Looking forward to seeing what comes out of CORD.

    1. What problems have you encountered in your EM Conference / Academic Day proceedings?

    As mentioned, a lot of this has been covered in the responses above. I would only add that the issues we see on the learner’s side of things (general lack of interest, faces buried in devices/laptops) have more to do with the existing structure and lack of a learner-centered model; the responsibility here lies with those planning conference and providing didactics. Before ubiquitous connectivity, lecturers had a relatively captive audience and thus, for better or worse, there was less of a *need* for learner engagement. I would argue that now, more than ever, interactive didactics that encourage learner engagement are needed to keep the kids interested and off of the Facebook.

    2. What are problems that you can identify in the above case? Are there any specific problems that resonate with you?

    Couple of things stand out:

    – lack of a DRI for curriculum; no one knows who the ‘curriculum lead’ is

    – M&M discussion doesn’t seem geared towards using mistakes as an opportunity for growth and/or identify easily remedied areas for improvement; M&M conferences in particular need to have a culture of ‘psychological safety’ where voices can be heard and ‘stupid’ questions can be asked without fear of judgment or retribution

    – quiz that was provided after required readings seems to have missed an opportunity to reinforce concepts learned in the assigned text; simply giving a quiz for the purpose of ensuring that the residents completed the assigned readings is useless with respect to the adult learner

    I’d echo the sentiments of Jeff with respect to ideas for improvement. And while I agree that the existing paradigm of 4-5 hours of required weekly didactics could use a massive overhaul, there are plenty of opportunities to improve within the existing structure.

  • Kory London

    **What problems have you encountered in your EM Conference / Academic Day proceedings?

    1. Many points have been made but I think a huge one are not just boring lectures, but context free lectures. If you are having powerpoint presentations, it shouldn’t be just a regurgitation of some textbook.

    2. EM physicians were not made to sit for 5 straight hours. Given contraint on resident time and duty hours, it’s understandable why the conference day is grouped together, but nobody says it has to be 5 hours of monotone didactic lectures.

    **What are problems that you can identify in the above case? Are there any specific problems that resonate with you?

    While the case is exaggerated, there is literally no discussion during this imaginary conference. The sole benefit of having group conference is to facilitate discussion. Not even discussing the quiz answers in a timely manner, guh.

    I could echo many people below, the biggest problem I see is a poorly motivated/incentivized faculty. CORD supports ‘Core Faculty’ designations for a reason. If you are getting a time buy down or a title for being core faculty, it should come with responsibility to provide and attend the lectures and participate/facilitate group discussion. It should never be the sole responsibility of the senior residents to give the majority of the lectures.

    I feel empathy for the program director and how difficult a job it is, but central to the job is not only providing an education that will not have accreditation revoked but also provide space for educational innovation.

    What are some solutions you have encountered or seen with regards to rejuvenating academic proceedings for residency programs?

    (for problem 1): Didactics can be interesting when attached to something tangible, like case presentations (for example: ‘Best Case Ever’ podcast), breaking to have discussions about points (has anyone actually seen hyperviscosity syndrome or salicylate toxicity, etc.).

    (for problem 2): Use a variety of educational modalities.
    -Sim is obvious and necessary
    -Flipped classrooms (my specific definition: everyone brings a computer, group work to find solutions to questions posed either by faculty regarding a specific topic or residents based on clinical questions and group presentations of what was found)
    -Jeopardy style quizes (once/week with prizes, provides incentive to show up, everyone loves giftcards).
    -Asynchronous learning (my current department uses ALIEM’s AIR series but Michigan, where I was before, used a variety of resources such as EMRAP, Amal Mattu’s EKG books, local/regional conference attendance, legislative outreach days, etc.)

    • Hi Kory
      How do you incentivise people to become CORE FACULTY? It sounds like there are some financial incentives, but if you can make as much (or more) working a community shift, how do you get people to sign on?

  • Will Goldenberg

    There are many issues in this case. Sounds like the faculty (including the PD) are not supportive as they could be. The PD and the chair need to support their junior faculty in the overhaul of the curriculum.

    Facutly need to show up at conference, that is part of our resposnibility at an academic institution. Where I previously worked, we had two levels of faculty- clinical and core. Core faculty have more of a buydown but they have more requirements for academics including assigend conference days. If you could not make the conference you had to switch with someone as that was a “shift”.
    Regarding CME: we did this too and even the clinical faculty began to show up at conference.

    Perhaps Jill can presents to the chair and the PD why some of these educational developments (asynch, etc) are beneficial to the program. Once receiving their buy in and support, she can begin to change the conference. I think she should have an overall curriculum plan for what she wants to develop but also be willing to just change a small subset of conference at a time-maybe add in a new type of conference, or change the way M and M is conducted. M & M is usully a highlight of our conference day as faculty have thoughts on the managment and often can be a great learning opportunity for all.
    Additionally shorter lectures (20 min) are received better by faculty and residents.

  • Antonia Quinn

    Has anyone thought about increasing faculty buy-in by promoting faculty development. Many longstanding faculty are still giving lectures in the old-school “death by Bulletpoint model” because that it what they are used to. Invite speakers to faculty meeting to teach how to build an exciting lecture for example. This may be a way to get creative juices flowing for the faculty and get them re-engaged and get excited to teach again.