Christopher I. Doty, MD FAAEM FACEP
Program Director and Vice-Chair, University of Kentucky
I have been in residency education for my entire academic career. I’ve had the honor of serving as a Program Director since 2002 and have participated in training of over 350 residents. Initially, I became interested in curriculum development during my chief residency at Kings County Hospital/SUNY Downstate. When I became a faculty member, I searched for and struggled to identify ways to engage learners with innovative new strategies and keep the tired, busy residents interested and actively participating each week. It has been a journey of many failures and gradual small successes. Over the past 7 years, I have worked in earnest to create learner-centered models of education at my programs; first at Kings County/SUNY Downstate and later at the University of Kentucky. That is to say that the entire curriculum is structured around a learner-needs-analysis to inform what needs to be kept, what needs to be discarded, and what needs to be amplified in our programs. I believe that true learner-centered models in medical education are possible with several significant departures from our standard previous education models.
Different Models of Education
- Keep doing what we have always done
- If it ain’t broke, don’t fix it
- Building curricula around the rotations that exist
- Building curricula around what is known about a topic
- Building curricula around what the preceptor knows
- Building curricula around the expertise you presently have access to
- Curricula built with the “end” in mind…. informed by a desired outcome
- Preceded by a learner-needs-analysis
- Build on adult learning theory principles (Andragogy) to ensure maximal impact and retention
- Release of some control back to the residents as partners/active consumers in their own education
Rotational planning in MedEd should begin not with identification of what is possible, but with a set of goals and objectives (G&O) for a content area. These G&O act as a sort of learner-needs-analysis for the residents on the various rotations. In my experience, the reverse sequence of curricula development is used usually. The program leadership looks at various rotations and develops a set of goals and objectives that are taught on those rotations. This seems backwards to me. I advocate for a more prospective approach. Developing the G&O and then working to make the existing rotation experience match those. I feel that the rotational experience and the goals and objectives should be married and should walk in lockstep as the program progresses. The rotational experience should always mirror the goals and objectives for that rotation and vice versa. Rotations that do not provide critical experience to the residents should not be considered in the core rotational curriculum. Of note, there are several rotations that are mandated by the RRC to be included in the curriculum. I do not advocate breaking these rules, but encourage program leaders to identify rotations at their institutions that can’t meet their desired G&O.
As an example, if the program leadership feels like critical care skills with neonates is required for its learners, beginning the planning of a NICU rotation by identifying and then committing to core G&O for that rotation should be done before any other preliminary talks or planning regarding building that rotation for the residents. Once the G&O for the NICU rotation are identified, then discussion with the faculty in the NICU can begin. This will inform the discussion of the rotation. After discussion with the NICU faculty, if your NICU rotation will not meet your learners’ needs, then you have learned a very useful bit of information. The search for an appropriate rotation can begin or the program leadership can augment the learning of the residents in other parts of the overall program curriculum to fulfill the missing G&O needs. In our example, we can develop a module to teach neonatal intubation skills if the NICU rotation cannot reliably provide that experience.
What has worked in the past (and not that well) might certainly not work now. There has been a tectonic shift in way students access resources, memorize information and think about learning over the past 5-7 years. Learners today have access to an amount of information that is orders of magnitude more than the previous generation of learners. In many ways, there is too much information to reasonably be able to filter what is useful and what isn’t. Interestingly, in my opinion, it requires physicians with a fair amount of clinical experience to be able to evaluate the utility of any particular information source or even a tidbit of information. Beginning learners will have difficulty putting new information into context and weighing the relative importance of new information. As an example, many of my residents will spend hours listening to podcasts about how to use ECMO in the ED but spend very little time learning about the challenges of treating low-risk chest pain. I think that having a more senior clinician help curate and provide a “relative weight” of the resources is very important. Learner centered models focus on what learners need, not necessarily what they want. Therefore, the best learner-centered models in MedEd will focus on 2 important principles: Andragogy and the curating of high-yield resources that have been selected for their importance to the goal-outcome.
Weekly education conference has traditionally been several hours of unidirectional communication with a significant dependence on slide sets (PowerPoint, Prezi, Keynote, etc.) to “deliver content”. This was the norm in medical school and usually was the norm for GME as well. Of no great surprise to anyone, 5 hours of passive learning is very low-yield and often not highly valued by the learner. See figure 1.
The challenge with creating curricula is that which we have always done, is usually what is most easy to do. We, as educators, often pick the path of least resistance. We also use the modality that we have seen modeled by our own educators. We use what we know. We know large-group-unidirectional lecture. That is how we were taught.
One of the large challenges to modern MedEd is that creating more engaging formats takes more work for EVERYONE, and everyone is strapped for time. It is a HUGE investment to create more engaging models for weekly conference. It requires much more work for the presenter, however it takes more work for the learner as well. Being in an active learning environment is more work for the learner. They are no longer being spoon fed the info. The new model requires cognitive work on the part of the learner in order to make the most out of the session.
I have moved away from traditional slide sets in the classic form. I still let the faculty and residents use slides when presenting in a large-group lecture, but demand the slides be used with some audience engagement adjunct. These can include: focused simulation, audience response cards or polling systems (Poll Everywhere or TurningPoint), enhanced slide delivery programs (NearPod), quizzes, videos, calling on participants, and gaming. This allows slide sets to be more engaging while still using the advantage of the slide talk (quick delivery of a relatively large amount of basic content.
Other Learning Modalities/Sessions
However, we use several other newer modalities to engage audiences as well. I use a fiercely modular curriculum in conference so we cover similar topics in the same day. This allows the learner to build knowledge off of information recently learned and provides structure for independent self-study. In each module, we use several other types of learning sessions:
We will identify a controversy in the literature and assign residents a side to argue on. The resident is responsible for doing a lit search with a faculty mentor and several other residents on their team. They then present that research in a debate format in conference. Each team has three or four residents and a faculty mentor and the entire session is moderated by a senior faculty member judge as well. The debate is structured with time for opening remarks, several rebuttals, and closing remarks. The audience votes on who won the debate but is engaged while listening to what amounts to be an extensive journal club on several papers and moderated discussion about an important clinical topic.
We have a senior resident assigned to design one experiential learning lab for each module. For example, during the trauma block, this resident was responsible for developing a low fidelity simulation model for placing chest tubes. During the GI module, the experiential lab was placing Blakemore tubes in a model of a profusely bleeding patient. The resident responsible for designing these labs is gaining experience in their “track” of medical education. I will discuss tracks below.
Small group moderated discussion:
We assign content to be read (listened to/watched) at home and this content is then discussed in a small group session that is moderated by a faculty member and a senior resident. The small group sessions keep the learners much more engaged because the communication environment and feeling of the session is more intimate. This does require some space considerations. The content delivery is a flipped classroom model.
This is a small group format that I developed with Dr. Eric Morley. This was a case-based-learning format where we developed a clinical vignette of a case in the ED that contains/evolves through several clinical questions that could be answered in evidence-based way or where debates existed in the medical literature. The patient in the case would decompensate throughout the vignette and the questions/decisions would get more difficult and complex. We assigned more junior residents the easier questions and senior residents the more complex questions. Presenters are assigned ahead of time to research a clinical question. These questions had been extracted from the vignette and the presenter-residents were instructed to find the 1-2 best papers to answer that clinical question. They were given this question 4-6 weeks before the presentation.
On the day of the actual session, every resident in that PGY class is responsible for being a “content expert” on those two papers and therefore some aspect of the clinical vignette. The presenting-resident worked with a faculty mentor to identify the best papers to answer their particular question.
The program then breaks into small groups that go through the clinical vignette. As the case progressed, each PGY class would, in turn, have an opportunity to present literature on their topic. This provided an environment where every resident was a content expert on some aspect of the case and was a team teaching/ team learning environment, moderated discussion. In this format, the residents presented and the faculty moderated.
This model has several advantages and several goals. It provides residents with the lifelong learning skills of doing a complete literature search and selecting the best evidence to answer a clinical question. It promotes confidence as each PGY class, even the interns, feel as though they are the content experts on their question. It also allows a team teaching/team learning environment as no individual resident has to present ‘perfectly” as there were always several members of each PGY class. It also promotes accountability, because any resident that has not read their papers is very obviously unable to lead the discussion during their part of the vignette (and looks bad in front of their peers). A faculty member is present in order to provide overall moderation and add clinical experience to the case.
Group directed simulation:
In each module, we use a commercial product called ISimulate to bring simulation into the classroom. ISimulate provides all the benefits of simulation without the bulkiness of a mannequin. Obviously, a mannequin could be brought in for the session as well. One or two residents are brought to the front of the conference room and manage a case relevant to the module. At various points in the case, the play of the simulation is stopped, and the audience gets to vote on the next step. This allows the audience to participate in the simulation as well and keeps them engaged as they never know when the next audience decision will be made. Due to the fact that there are multiple learners involved, the cases can be more complex than a normal simulation case.
We are presently developing a new session that is centered around a mock trial format. A case will be selected that had an adverse outcome or unexpected morbidity. The resident will be “subpoenaed” and will have to prepare their defense. The resident’s chart will be read and dissected and must be defended by the resident. They will receive cross-examination and be represented by a “lawyer” (faculty member). There will also be a judge (moderator) and jury (audience). This will allow the learning session to focus on a morbidity and mortality topic, cognitive and systems errors, ED process, team dynamics, medical decision-making, chart documentation, medical legal aspects of Emergency Medicine, and patient centered communication.
Lastly, a learner-centered curriculum should engage learners where they presently exist. There needs to be a standard of competence in the core clinical abilities of the residents, but creating cookie-cutter residents should be discouraged. Each resident is invited and encouraged, to seek their area of excellence outside of clinical emergency medicine. This track or role is supported and potentiated by the leadership of the program. It is the leadership’s responsibility to find and deliver mentorship to the residents in their chosen field of specialization. This allows the program to engage the residents in what they are most passionate about, and therefore maximize their “extracurricular” productivity.
This field of excellence could be in medical education, simulation, POCUS, pediatrics, geriatrics, information technology, operations, research, public health, health policy, quality improvement, administration, emergency medical services, or any other field of emergency medicine. This is more of a mentality then a structure. The program’s only commitment is to support this development and assure mentorship in the relevant subspecialty. This allows the program to truly invest in their solitary product line, the present residents and graduates of the program.
- Begin with the ending in mind. What is your desired outcome?
- Develop a learner needs analysis before any education as a first step in planning any educational project, module, or endeavor.
- PowerPoint slide sets do not have to be eliminated, but should be deemphasized. Remaining use of slide sets can be augmented with learner engagement adjuncts.
- Small group learning sessions, moderating discussions, journal clubs, and experiential learning labs will keep an otherwise boring conference very engaging.
- Paper is a dead technology. Let’s stop investing in that. Encourage residents to bring electronic devices to conference but they need to be responsible with them. Tetris is strongly discouraged, but looking up a supporting/refuting article should be very much encouraged.
- Creating a conference that works on sound adult learning principles is a lot of work on the front end. However, it becomes the culture eventually and gets much easier once the faculty and residents buy in. Over a few years, it is all the residents have ever known.
- Mentorship can be done remotely. Not every mentor has to be local.
- The department can get tremendous output from the residents at the same time the residents are developing a set of deliverables on their CV to assist them in landing a job of their choice in the future.
Figure 1. (NO science was used in the making of this graphic….but I still sort of believe it)