- Email: [email protected]
E-mail amplification of a mock code teaching round1
The Journal of Emergency Medicine, Vol. 20, No. 3, pp. 307–314, 2001 Copyright © 2001 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/01 $–see front matter
PII S0736-4679(01)00289-X
Education
E-MAIL AMPLIFICATION OF A MOCK CODE TEACHING ROUND Martin V. Pusic,
MD*
and Brett W. Taylor,
MD†
*Department of Medical Informatics, Columbia University, New York, New York and †Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia Reprint Address: Martin V. Pusic, MD, Dept. of Medical Informatics, Columbia University, 622 West 168th Street, Vanderbilt Clinic Bldg, Fifth Floor, New York, NY 10032-3270
e Abstract—To determine whether e-mail could be used to supplement a teaching round, we implemented the following educational intervention: each Monday, a mock code was presented. Two e-mails were then sent the same day to all residents. One summarized the main teaching points whereas the second solicited discussion. Each Friday, a third e-mail was sent that summarized the discussion. We collected all e-mails and surveyed the residents. Fifteen of 18 residents completed the questionnaire; two were not participants in the e-round. Forty percent (7/15) of the residents attended fewer than half of the mock codes but most participants (10/13) reported reading >95% of the e-mails. A majority reported storing (11/13), printing (7/ 13), and reading e-mails a second time (12/13). Seven of 13 reported learning as much or more from the e-mails as from the mock code itself. We conclude that e-mail can increase learning from a traditional mock code teaching round. © 2001 Elsevier Science Inc.
is expected to be able to initiate treatment of conditions such as aspirated foreign body, anaphylaxis, and supraventricular tachycardia. However, because these cases are uncommon, pediatric residents are unlikely to see, let alone direct the care of, a significant number of them during their comparatively brief rotations through the pediatric emergency department (PED). Pediatric Advanced Life Support and Advanced Pediatric Life Support (APLS) courses have done much to fill this educational void. However, not all pediatric residents have the opportunity to take these courses. Even those who do will likely do so only once during their training with little opportunity for reinforcement. Regular mock codes can do much to correct this knowledge gap (1). In a mock code, a trainee is asked to role-play the resuscitation leader for a given clinical scenario. Other trainees can play secondary roles as members of the “resuscitation team.” The scenario is constructed so as to force the trainee into active decisionmaking. The instructor presents clinical information in the manner in which it might be uncovered in an actual code. Aids such as rhythm generators and make-up can add to the realism of the scenario. After the case has been brought to its natural conclusion, the instructor and the other trainees debrief the trainee who ran the code. Constructive feedback is given and educational points are discussed. Mock codes can effectively teach knowledge points (e.g., recognition of cardiac rhythms) and
INTRODUCTION Active educational measures are required to ensure that pediatric residents have the knowledge and skill to appropriately treat critically ill children. Every pediatrician These results were first presented at the Ambulatory Pediatrics Association Annual Meeting May 1, 1999, San Francisco, California.
Education is coordinated by Stephen R. Hayden, Diego, California
RECEIVED: 19 April 2000; FINAL ACCEPTED: 9 October 2000
SUBMISSION RECEIVED:
MD,
of the University of California San Diego Medical Center, San
30 August 2000; 307
308
M. V. Pusic and B. W. Taylor
skills (e.g., use of monitoring equipment). In addition, the psychological stress of performing these maneuvers before an audience of one’s peers may stand the trainee in good stead when confronted with the emotional challenge of leading an actual critical care situation. At our institution, we began a program of weekly mock codes loosely based on those suggested by Roback (1). Although the rounds were well received by the residents, logistical problems prevented our realizing the full potential of the round. We found that only about a third of the residents could attend because of their commitments to service and distant rotations. In addition, many of the possible educational points that arose from a given case could not be discussed during the round because of time constraints. E-mail is just beginning to find a role in clinical teaching. Its advantages include efficiency in distributing learning content, capacity for bi-directional communication, its non-threatening nature, and sheer convenience. E-mail alone has been used successfully as a teaching medium in nursing education, gynecology, and Pediatric Emergency Medicine (2). These “virtual” rounds have usually consisted of sending multiple-choice questions to residents and soliciting their responses. They have been presented as separate activities not directly linked to personal teaching. We postulated that an e-mail round given in conjunction with a traditional teaching round could take advantage of the best features of each. The e-mail portion of the round could reach the residents who were not able to attend the actual round, and for the residents who had attended, e-mail could reinforce the educational principles they had learned. We also hoped to generate discussion beyond what had been presented at the actual round.
MATERIALS AND METHODS Setting The IWK-Grace Health Center is a tertiary-care university-affiliated pediatric hospital serving the Maritime provinces of Canada. It supports an accredited four-year pediatric residency. Residents typically do 2 to 3 months of rotations in the Pediatric Emergency Department, mainly in the first year. There are four Emergency Medicine residents who do a 1-month rotation each year. Six full-time attending pediatricians, three of whom are board-certified in Pediatric Emergency Medicine, staff the pediatric Emergency Department (PED). The annual census of the PED is 35,000.
Subjects The mock code round was presented weekly to all pediatric residents at the IWK-Grace Health Center beginning in September 1997. The supplementary e-mails were initiated in November 1997 with residents participating on a voluntary basis. The round and e-mails continued until June 15, 1998, when a six-page questionnaire was mailed to all pediatric residents. Consent was inferred from the return of the surveys by hospital mail.
E-mail Environment The e-mail system at the IWK-Grace uses commercial software (CC: Mail, Lotus Development Inc, Cambridge, Massachusetts) installed in 1993. All residents are given their own individual account, with access available at numerous workstations within the institution. In addition, some residents elect to maintain their e-mail accounts with either Dalhousie University or commercial providers. Home access was available for most residents. Except for our study, resident e-mail was used principally for communication between the residents themselves, usually around issues of scheduling and other administrative issues. Most official communication with the residents was, at that time, done by paper.
Mock Code In September 1997, we began presenting mock codes each Monday morning to all available pediatric and off-service residents and medical students. A single PED attending physician presented the majority of the mock codes. Typically, trainees were assigned roles including code leader, airway physician, and nurse. The attending would initially present a brief clinical scenario (e.g., “A 4-year-old male presents blue and apneic after choking on a hot-dog”). Using a mannequin, the trainees would role-play resuscitating the described child. Monitors would be attached, bag-valve-mask ventilation initiated, sham intravenous or intraosseus needles placed, drugs and dosages called out, cardioversion attempted, etc. The attending would supply only clinical information such as vital signs, additional history, and response to the team’s maneuvers. After the scenario had played out, the attending would stop the role-play. He then facilitated a discussion of the key management principles brought out by the case and the way the team had handled it. We did not design a specific curriculum for the Mock Code Round, choosing instead to base the case presentations loosely on those listed in the APLS course manual and a published manual of mock codes (Table 1) (1).
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309
Table 1. Mock Code Scenarios Airway basics Breathing basics Circulation basics Anaphylaxis Asthma Burns and smoke inhalation Coarctation of the aorta Coma Dehydration Digoxin overdose Drowning Facial trauma Fentanyl-induced chest wall rigidity
Hydrocarbon aspiration Hypothermia Malignant hypertension Pulmonary contusion Salicylate poisoning Sickle cell disease–chest syndrome Status epilepticus Sudden infant death syndrome Supraventricular tachycardia Traumatic blood loss Tricyclic antidepressant overdose Upper airway foreign body VP shunt obstruction
No matter what the particular case presented, we strove to emphasize the importance of basic resuscitation principles (the ABCs). To illustrate the relevancy of critical care skills, as often as practicable we presented cases that had been encountered recently within the hospital.
Mock Code E-mails In November 1997, all pediatric residents and PEM faculty were invited to join a “Mock code discussion list” moderated by one of the authors. To join, residents needed only to supply their e-mail addresses. Participation was entirely voluntary and had no influence on resident evaluation. Residents could withdraw at any time. Three e-mail messages were sent each week to supplement the Mock Code Round. The first message was sent after the mock code on the Monday. The message summarized the case presented and the main teaching points (Figure 1—the “case summary” e-mail). It was intended to be self-contained such that a trainee who had not been able to attend the mock code would nonetheless be made aware of the teaching points raised. A second e-mail (Figure 2—the “discussion” e-mail) presented a point of discussion to all the participants (e.g., “what are the relative advantages of Drug A vs. Drug B in this case?”). Over the course of the week, responses to the discussion e-mail were collected. Each Friday, the responses, stripped of identifiers, were collated into a single e-mail with an “expert” commentary (Figure 3—the “discussion summary” e-mail). The e-mail program used to maintain the lists and send the e-mails was Netscape Messenger Version 3.0 (Netscape Communications Corporation, Mountain View, California). All e-mail messages were sent from the round leader’s home.
Figure 1. Example of a Mock Code Summary e-mail. This first of three e-mails summarized the case and reiterated the teaching points presented at the mock code earlier in the day.
Survey The residents were surveyed in June 1998. The selfadministered questionnaire consisted of two parts: a 53item survey of their general computer-related experience and attitudes that we had used in a previous study (3) and a second section of 24 questions regarding their e-mail
Figure 2. Example of a Discussion Point e-mail. This e-mail was sent at the same time as the Summary e-mail. It presents a point for discussion that was not addressed during the Mock Code Round.
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Figure 3. Example of a Discussion Summary E-mail. This third e-mail collated the resident responses to the discussion point and presented a commentary on the responses as well as the round leader’s opinion on the discussion point.
usage and their attitudes toward the mock code e-mail round.
Statistics Descriptive statistics were used to summarize the survey responses. For proportional data, comparisons were made using the 2 test. Comparison of the residents’ ranking of teaching methods was performed using the Wilcoxon signed rank test. All tests were two-tailed with significance at ␣ ⬍0.05.
RESULTS Attendance at the mock code varied between one and nine trainees. Sixteen of our 18 pediatric residents participated in the e-mail round. The round leader sent 78 e-mail messages during the study period (three per week). The total number of cases presented was 26. The e-mails totaled 35 pages of single-spaced type-written material (68 kilobytes). Resident responses to the discussion point averaged three messages per case (79 in total; range 0 –5) with 55 (69%) coming from three (17%) of the residents. Five of the residents sent one or fewer e-mail messages.
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Table 2. Resident Computer Ownership and Use
Residents Sex (% female) Own a computer Have Internet access at home Number of times Internet accessed per week Regularly access medical education sites on the Internet Have seen an X-ray on the Internet Number of e-mail accounts per resident Check e-mail: Less than once/day At least daily More than once a day Only at home Only at work Both at home and at work Check e-mail: While on vacation While on out-of-city rotation
(n ⫽ 15) (unless otherwise specified) 13 (80%) 7 (47%) 6 (40%) Median 1 Range (0–10) 8 (53%) 4 (27%) Median 1 Range 1–4 0 15 (100%) 5 (33%) 2 (13%) 8 (53%) 5 (33%) 5 (33%) 3/6 (50%)
Fifteen of 18 residents completed the questionnaire. Of these, two were not participants in the e-mail portion of the round. Characteristics of computer usage by the residents are shown in Table 2. All residents reported checking their e-mail at least once per day. Forty percent (7/15) of the residents reported attending fewer than 50% of the Mock Codes, but 10 of 13 participants reported
Table 3. Resident Attribution of Learning from the Mock Code Round
Mock code itself E-mail summary E-mail discussion
Mean
95% Confidence Interval
52% 29% 19%
40, 64% 23, 35% 13, 25%
The residents were asked: “Thinking back over the course of the year since the e-mail round was started and taking into account your attendance at mock codes, assign percentages (to total 100%) to how much you learned from each of. . . (the above listed elements of the round).
reading ⬎ 5% of the e-mails (Figure 4). Asked if they had ever skipped the round because they knew they would get an e-mail summary, all 13 participants replied no. A majority of participants reported storing (11/13), printing (7/13), and reading e-mails a second time (12/ 13). Residents; attribution of their learning from the various components of the round is listed in Table 3. All of the participants attributed at least 25% of their learning to the e-mails. Seven of 13 reported learning as much or more from the e-mail round as from the mock code itself. The four residents with below median attendance attributed more of their total learning to the e-mails than did those with median or greater attendance (60% vs. 41%, respectively; p ⫽ 0.07). Residents felt they learned more from the Summary e-mail than from the Discussion
Figure 4. Resident self-report of attendance at mock code and proportion of e-mails read.
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Figure 5. Resident rankings of mock code e-round compared with other teaching interventions. The residents were asked to rank the following five teaching interventions from 1 (most valuable) to 5 (least): the two mock code e-mails, five minutes of bedside teaching by either an attending pediatrician or a more senior resident and 5 min spent reading a relevant journal article. Each diamond (⽧) represents one resident’s ranking while the club (⽤) represents the median for that teaching intervention. Example: nine residents ranked teaching by an attending pediatrician ahead of all the other interventions.
(12/13; p ⬍ 0.001). The residents’ rankings of the round compared with other teaching interventions are shown in Figure 5. All felt the e-mails were more valuable than 5 min spent reading a journal (p ⫽ 0.001). The main barrier to sending an e-mail comment was reported to be lack of time (6/8). Only one resident listed concern about peers’ perceptions as a barrier.
DISCUSSION E-mail has been used successfully in a number of medical education settings. Letterie et al. were among the first to describe the use of e-mail to teach residents (4). Using a hospital e-mail system, they sent one board-type multiple-choice review question to each of their gynecology residents daily for 60 days. Residents were given 24 h to respond and comment. The answer to the question and appropriate references were sent to the residents within 48 h of the initial question. Residents embraced the round enthusiastically. Average daily participation was 85% with the residents giving the overall program a rating of 5.0 on a scale from 1 to 6 where 6 was highest. They also found that the e-mail teaching program successfully raised post-test scores compared with scores on the same questions e-mailed during the year. The study design did not include a control group and was susceptible to confounding due to residents gaining knowledge from other educational activities over time. Komorowski used a similar format to teach pediatric emergency medicine to pediatric residents at the Arkan-
sas Children’s Hospital (2). She sent daily multiplechoice questions to the residents and solicited their responses. The next day, the answer and discussion were sent out along with the next question. The round was presented each weekday of the academic year for 3 years. Over this longer term, the residents responded less frequently (the average daily participation rate for the first year of the round was 23% and declined in subsequent years). Interestingly, the residents were nonetheless enthusiastic about the round, preferring it to Grand Rounds and their Resident Lecture Series. We used e-mail to improve an existing teaching activity, namely a mock code teaching round. The mock code is a well-established teaching activity that is thought to effectively teach cognitive, attitudinal, and psychomotor aspects of leading the resuscitation of a critically ill patient (1). Logistical obstacles, including relatively few ED rotations, call obligations, and remote rotations, preclude the residents from attending every mock code. We postulated that an e-mail summary and discussion of the week’s mock code could provide a minimum of uniform cognitive instruction for those who were unable to attend (often the majority) and would augment the learning experience for those who had attended. We were pleased with the results of the e-mail round. All but two of our residents participated. The participants reported reading the vast majority of the e-mails and attributed almost half of their learning from the round as a whole, to the e-mails. This suggests that e-mail can compensate for scheduling difficulties. In addition, a
E-mail Amplification of Mock Codes
majority of the residents stored the e-mails and occasionally referred to them later. We had the impression that the three e-mails per week entitled “Mock Code” had a positive effect on both round attendance and the residents’ general attitude toward the round. The e-mails reinforced the principle that the mock code was for all residents and not just those on rotation in the ED. Another positive aspect of the round was its perceived efficiency for both the teacher and learner. The round leader was able to send the e-mails from his home. The residents were able to read them at times convenient to them. Textual information delivered by e-mail cannot replace the simulation of a code experience by an experienced clinician-educator. This is especially true for affective and psychomotor learning points. The fact that many residents reported learning more from the e-mail round than from the mock code itself likely reflects the fixed scheduling difficulties experienced by our pediatric residents. It is a formidable logistic challenge to ensure weekly pediatric resident attendance at an Emergency Medicine teaching round for the full academic year. However, even if the scheduling difficulties could be resolved, e-mails would likely still be an efficient supplement. With little instructor effort, they would reinforce teaching points made at the mock code. We noted that even residents who attended 75–95% of the rounds reported significant (25%) learning from the e-mails. Our round had essentially two parts: an e-mail summary of what took place at the mock code and a related e-mail discussion. The residents clearly attributed more of their learning to the e-mail summary of the mock code case than to the e-mail discussion point. This is surprising, because one would think that one of e-mail’s key educational features is the capacity for bi-directional communication. One possible explanation is that the summary e-mail provided those who were able to attend the mock code an opportunity to reflect on what they had learned. This is an essential component of adult learning that is often sacrificed to time-pressures (5). Other possible reasons why the discussion point was less popular than the summary may include: the inefficiency of reading possible wrong answers from fellow residents, the domination of the discussion by relatively few residents, lack of time to personally participate in the discussion, and questions of anonymity. Our finding supports that of Komorowski who, after 3 years of steadily decreasing resident responses, has eliminated this feature of her round (2). However, we still believe there is benefit to the discussion point since our residents attributed fully 19% of their total learning from the entire round to the discussion e-mails. That e-mail discussions can be of benefit even though relatively few actively participate is supported by the
313
“lurking” behavior of the majority of e-mail listserv subscribers. Steele described the usage of the ped-em-l listserv that allows PEM practitioners to communicate widely among themselves (6). He found that, of the 1112 subscribers of the listserv, only 4% regularly contributed. This may result in an unbalanced discussion dominated by a few vocal members. In an unmoderated listserv, this goes unchecked. In a local e-mail discussion group such as the one described, an active, visible round leader can ensure a balanced learning experience. Ours is clearly only an exploratory study. We have not provided objective evidence of improved learning outcomes. While we surveyed the attitudes of almost all of our residents, our program is small. The results may not be generalizeable to other institutions; however, we feel that the idea is sufficiently compelling and easily implemented that other residency programs would do well to experiment with it. At the time of this round, ours was the only division within the hospital to use this novel form of teaching. Since resident time for reading e-mail is not limitless, the round might not be as effective if other subspecialties also held similar rounds. More sophisticated e-mail instructional tools are available. We used a simple text-based format but the incorporation of multi-media, including graphics, sound and video, into e-mail is possible (7). In addition, software environments such as WebCT (WebCT Inc, Peabody Massachusetts) and Learning Space (Lotus Development Corporation, Cambridge, Massachusetts) allow for archiving of e-mails, exchange of files, multiplechoice testing, tracking of student activity, and numerous other functions. Web sites such as www.e-circles.com and www.yahoo.com offer increasingly sophisticated electronic bulletin boards and chat functions. How much these added functions could contribute to resident learning should be explored. In summary, e-mail can be used to amplify resident learning from a traditional round. It is an efficient form of teaching that is popular with residents. The best format for e-mail discussion remains to be defined. We encourage other centers to experiment with this and other forms of e-mail teaching.
Acknowledgments—The authors wish to thank the IWK-Grace pediatric residents for their cheerful participation in the mock code round. We also wish to thank Dr. Terry Gandell for her helpful review of the manuscript.
REFERENCES 1. Roback MG, Teach SJ, First LR, Fleisher GR. Handbook of Pediatric Mock Codes. St. Louis: Mosby-Year Book Inc; 1998.
314 2. Komoroski EM. Use of e-mail to teach residents pediatric emergency medicine. Arch PediatrAdoles Med 1998;152:1141– 6. 3. Pusic MV. Pediatric residents: are they ready to use computeraided instruction? Arch PediatrAdoles Med 1998;152:494 – 8. 4. Letterie GS, Morgenstern LL, Johnson L. The role of an electronic mail system in the educational strategies of a residency in obstetrics and gynecology. Obstet Gynecol 1994;84:137–9.
M. V. Pusic and B. W. Taylor 5. Burge EJ. Learning in computer conferenced contexts: the learners’ perspective. J Distance Education 1991;9:19 – 43. 6. Steele DW. Ped-Em-L: An Internet Discussion List for Pediatric Emergency Medicine. 38th Annual Meeting of the Ambulatory Pediatrics Association 1998; Abstract Number 350. 7. Plain SW. The client side of E-mail. PC Magazine 1998;17:111– 56.
PII S0736-4679(01)00289-X
Education
E-MAIL AMPLIFICATION OF A MOCK CODE TEACHING ROUND Martin V. Pusic,
MD*
and Brett W. Taylor,
MD†
*Department of Medical Informatics, Columbia University, New York, New York and †Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia Reprint Address: Martin V. Pusic, MD, Dept. of Medical Informatics, Columbia University, 622 West 168th Street, Vanderbilt Clinic Bldg, Fifth Floor, New York, NY 10032-3270
e Abstract—To determine whether e-mail could be used to supplement a teaching round, we implemented the following educational intervention: each Monday, a mock code was presented. Two e-mails were then sent the same day to all residents. One summarized the main teaching points whereas the second solicited discussion. Each Friday, a third e-mail was sent that summarized the discussion. We collected all e-mails and surveyed the residents. Fifteen of 18 residents completed the questionnaire; two were not participants in the e-round. Forty percent (7/15) of the residents attended fewer than half of the mock codes but most participants (10/13) reported reading >95% of the e-mails. A majority reported storing (11/13), printing (7/ 13), and reading e-mails a second time (12/13). Seven of 13 reported learning as much or more from the e-mails as from the mock code itself. We conclude that e-mail can increase learning from a traditional mock code teaching round. © 2001 Elsevier Science Inc.
is expected to be able to initiate treatment of conditions such as aspirated foreign body, anaphylaxis, and supraventricular tachycardia. However, because these cases are uncommon, pediatric residents are unlikely to see, let alone direct the care of, a significant number of them during their comparatively brief rotations through the pediatric emergency department (PED). Pediatric Advanced Life Support and Advanced Pediatric Life Support (APLS) courses have done much to fill this educational void. However, not all pediatric residents have the opportunity to take these courses. Even those who do will likely do so only once during their training with little opportunity for reinforcement. Regular mock codes can do much to correct this knowledge gap (1). In a mock code, a trainee is asked to role-play the resuscitation leader for a given clinical scenario. Other trainees can play secondary roles as members of the “resuscitation team.” The scenario is constructed so as to force the trainee into active decisionmaking. The instructor presents clinical information in the manner in which it might be uncovered in an actual code. Aids such as rhythm generators and make-up can add to the realism of the scenario. After the case has been brought to its natural conclusion, the instructor and the other trainees debrief the trainee who ran the code. Constructive feedback is given and educational points are discussed. Mock codes can effectively teach knowledge points (e.g., recognition of cardiac rhythms) and
INTRODUCTION Active educational measures are required to ensure that pediatric residents have the knowledge and skill to appropriately treat critically ill children. Every pediatrician These results were first presented at the Ambulatory Pediatrics Association Annual Meeting May 1, 1999, San Francisco, California.
Education is coordinated by Stephen R. Hayden, Diego, California
RECEIVED: 19 April 2000; FINAL ACCEPTED: 9 October 2000
SUBMISSION RECEIVED:
MD,
of the University of California San Diego Medical Center, San
30 August 2000; 307
308
M. V. Pusic and B. W. Taylor
skills (e.g., use of monitoring equipment). In addition, the psychological stress of performing these maneuvers before an audience of one’s peers may stand the trainee in good stead when confronted with the emotional challenge of leading an actual critical care situation. At our institution, we began a program of weekly mock codes loosely based on those suggested by Roback (1). Although the rounds were well received by the residents, logistical problems prevented our realizing the full potential of the round. We found that only about a third of the residents could attend because of their commitments to service and distant rotations. In addition, many of the possible educational points that arose from a given case could not be discussed during the round because of time constraints. E-mail is just beginning to find a role in clinical teaching. Its advantages include efficiency in distributing learning content, capacity for bi-directional communication, its non-threatening nature, and sheer convenience. E-mail alone has been used successfully as a teaching medium in nursing education, gynecology, and Pediatric Emergency Medicine (2). These “virtual” rounds have usually consisted of sending multiple-choice questions to residents and soliciting their responses. They have been presented as separate activities not directly linked to personal teaching. We postulated that an e-mail round given in conjunction with a traditional teaching round could take advantage of the best features of each. The e-mail portion of the round could reach the residents who were not able to attend the actual round, and for the residents who had attended, e-mail could reinforce the educational principles they had learned. We also hoped to generate discussion beyond what had been presented at the actual round.
MATERIALS AND METHODS Setting The IWK-Grace Health Center is a tertiary-care university-affiliated pediatric hospital serving the Maritime provinces of Canada. It supports an accredited four-year pediatric residency. Residents typically do 2 to 3 months of rotations in the Pediatric Emergency Department, mainly in the first year. There are four Emergency Medicine residents who do a 1-month rotation each year. Six full-time attending pediatricians, three of whom are board-certified in Pediatric Emergency Medicine, staff the pediatric Emergency Department (PED). The annual census of the PED is 35,000.
Subjects The mock code round was presented weekly to all pediatric residents at the IWK-Grace Health Center beginning in September 1997. The supplementary e-mails were initiated in November 1997 with residents participating on a voluntary basis. The round and e-mails continued until June 15, 1998, when a six-page questionnaire was mailed to all pediatric residents. Consent was inferred from the return of the surveys by hospital mail.
E-mail Environment The e-mail system at the IWK-Grace uses commercial software (CC: Mail, Lotus Development Inc, Cambridge, Massachusetts) installed in 1993. All residents are given their own individual account, with access available at numerous workstations within the institution. In addition, some residents elect to maintain their e-mail accounts with either Dalhousie University or commercial providers. Home access was available for most residents. Except for our study, resident e-mail was used principally for communication between the residents themselves, usually around issues of scheduling and other administrative issues. Most official communication with the residents was, at that time, done by paper.
Mock Code In September 1997, we began presenting mock codes each Monday morning to all available pediatric and off-service residents and medical students. A single PED attending physician presented the majority of the mock codes. Typically, trainees were assigned roles including code leader, airway physician, and nurse. The attending would initially present a brief clinical scenario (e.g., “A 4-year-old male presents blue and apneic after choking on a hot-dog”). Using a mannequin, the trainees would role-play resuscitating the described child. Monitors would be attached, bag-valve-mask ventilation initiated, sham intravenous or intraosseus needles placed, drugs and dosages called out, cardioversion attempted, etc. The attending would supply only clinical information such as vital signs, additional history, and response to the team’s maneuvers. After the scenario had played out, the attending would stop the role-play. He then facilitated a discussion of the key management principles brought out by the case and the way the team had handled it. We did not design a specific curriculum for the Mock Code Round, choosing instead to base the case presentations loosely on those listed in the APLS course manual and a published manual of mock codes (Table 1) (1).
E-mail Amplification of Mock Codes
309
Table 1. Mock Code Scenarios Airway basics Breathing basics Circulation basics Anaphylaxis Asthma Burns and smoke inhalation Coarctation of the aorta Coma Dehydration Digoxin overdose Drowning Facial trauma Fentanyl-induced chest wall rigidity
Hydrocarbon aspiration Hypothermia Malignant hypertension Pulmonary contusion Salicylate poisoning Sickle cell disease–chest syndrome Status epilepticus Sudden infant death syndrome Supraventricular tachycardia Traumatic blood loss Tricyclic antidepressant overdose Upper airway foreign body VP shunt obstruction
No matter what the particular case presented, we strove to emphasize the importance of basic resuscitation principles (the ABCs). To illustrate the relevancy of critical care skills, as often as practicable we presented cases that had been encountered recently within the hospital.
Mock Code E-mails In November 1997, all pediatric residents and PEM faculty were invited to join a “Mock code discussion list” moderated by one of the authors. To join, residents needed only to supply their e-mail addresses. Participation was entirely voluntary and had no influence on resident evaluation. Residents could withdraw at any time. Three e-mail messages were sent each week to supplement the Mock Code Round. The first message was sent after the mock code on the Monday. The message summarized the case presented and the main teaching points (Figure 1—the “case summary” e-mail). It was intended to be self-contained such that a trainee who had not been able to attend the mock code would nonetheless be made aware of the teaching points raised. A second e-mail (Figure 2—the “discussion” e-mail) presented a point of discussion to all the participants (e.g., “what are the relative advantages of Drug A vs. Drug B in this case?”). Over the course of the week, responses to the discussion e-mail were collected. Each Friday, the responses, stripped of identifiers, were collated into a single e-mail with an “expert” commentary (Figure 3—the “discussion summary” e-mail). The e-mail program used to maintain the lists and send the e-mails was Netscape Messenger Version 3.0 (Netscape Communications Corporation, Mountain View, California). All e-mail messages were sent from the round leader’s home.
Figure 1. Example of a Mock Code Summary e-mail. This first of three e-mails summarized the case and reiterated the teaching points presented at the mock code earlier in the day.
Survey The residents were surveyed in June 1998. The selfadministered questionnaire consisted of two parts: a 53item survey of their general computer-related experience and attitudes that we had used in a previous study (3) and a second section of 24 questions regarding their e-mail
Figure 2. Example of a Discussion Point e-mail. This e-mail was sent at the same time as the Summary e-mail. It presents a point for discussion that was not addressed during the Mock Code Round.
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Figure 3. Example of a Discussion Summary E-mail. This third e-mail collated the resident responses to the discussion point and presented a commentary on the responses as well as the round leader’s opinion on the discussion point.
usage and their attitudes toward the mock code e-mail round.
Statistics Descriptive statistics were used to summarize the survey responses. For proportional data, comparisons were made using the 2 test. Comparison of the residents’ ranking of teaching methods was performed using the Wilcoxon signed rank test. All tests were two-tailed with significance at ␣ ⬍0.05.
RESULTS Attendance at the mock code varied between one and nine trainees. Sixteen of our 18 pediatric residents participated in the e-mail round. The round leader sent 78 e-mail messages during the study period (three per week). The total number of cases presented was 26. The e-mails totaled 35 pages of single-spaced type-written material (68 kilobytes). Resident responses to the discussion point averaged three messages per case (79 in total; range 0 –5) with 55 (69%) coming from three (17%) of the residents. Five of the residents sent one or fewer e-mail messages.
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Table 2. Resident Computer Ownership and Use
Residents Sex (% female) Own a computer Have Internet access at home Number of times Internet accessed per week Regularly access medical education sites on the Internet Have seen an X-ray on the Internet Number of e-mail accounts per resident Check e-mail: Less than once/day At least daily More than once a day Only at home Only at work Both at home and at work Check e-mail: While on vacation While on out-of-city rotation
(n ⫽ 15) (unless otherwise specified) 13 (80%) 7 (47%) 6 (40%) Median 1 Range (0–10) 8 (53%) 4 (27%) Median 1 Range 1–4 0 15 (100%) 5 (33%) 2 (13%) 8 (53%) 5 (33%) 5 (33%) 3/6 (50%)
Fifteen of 18 residents completed the questionnaire. Of these, two were not participants in the e-mail portion of the round. Characteristics of computer usage by the residents are shown in Table 2. All residents reported checking their e-mail at least once per day. Forty percent (7/15) of the residents reported attending fewer than 50% of the Mock Codes, but 10 of 13 participants reported
Table 3. Resident Attribution of Learning from the Mock Code Round
Mock code itself E-mail summary E-mail discussion
Mean
95% Confidence Interval
52% 29% 19%
40, 64% 23, 35% 13, 25%
The residents were asked: “Thinking back over the course of the year since the e-mail round was started and taking into account your attendance at mock codes, assign percentages (to total 100%) to how much you learned from each of. . . (the above listed elements of the round).
reading ⬎ 5% of the e-mails (Figure 4). Asked if they had ever skipped the round because they knew they would get an e-mail summary, all 13 participants replied no. A majority of participants reported storing (11/13), printing (7/13), and reading e-mails a second time (12/ 13). Residents; attribution of their learning from the various components of the round is listed in Table 3. All of the participants attributed at least 25% of their learning to the e-mails. Seven of 13 reported learning as much or more from the e-mail round as from the mock code itself. The four residents with below median attendance attributed more of their total learning to the e-mails than did those with median or greater attendance (60% vs. 41%, respectively; p ⫽ 0.07). Residents felt they learned more from the Summary e-mail than from the Discussion
Figure 4. Resident self-report of attendance at mock code and proportion of e-mails read.
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Figure 5. Resident rankings of mock code e-round compared with other teaching interventions. The residents were asked to rank the following five teaching interventions from 1 (most valuable) to 5 (least): the two mock code e-mails, five minutes of bedside teaching by either an attending pediatrician or a more senior resident and 5 min spent reading a relevant journal article. Each diamond (⽧) represents one resident’s ranking while the club (⽤) represents the median for that teaching intervention. Example: nine residents ranked teaching by an attending pediatrician ahead of all the other interventions.
(12/13; p ⬍ 0.001). The residents’ rankings of the round compared with other teaching interventions are shown in Figure 5. All felt the e-mails were more valuable than 5 min spent reading a journal (p ⫽ 0.001). The main barrier to sending an e-mail comment was reported to be lack of time (6/8). Only one resident listed concern about peers’ perceptions as a barrier.
DISCUSSION E-mail has been used successfully in a number of medical education settings. Letterie et al. were among the first to describe the use of e-mail to teach residents (4). Using a hospital e-mail system, they sent one board-type multiple-choice review question to each of their gynecology residents daily for 60 days. Residents were given 24 h to respond and comment. The answer to the question and appropriate references were sent to the residents within 48 h of the initial question. Residents embraced the round enthusiastically. Average daily participation was 85% with the residents giving the overall program a rating of 5.0 on a scale from 1 to 6 where 6 was highest. They also found that the e-mail teaching program successfully raised post-test scores compared with scores on the same questions e-mailed during the year. The study design did not include a control group and was susceptible to confounding due to residents gaining knowledge from other educational activities over time. Komorowski used a similar format to teach pediatric emergency medicine to pediatric residents at the Arkan-
sas Children’s Hospital (2). She sent daily multiplechoice questions to the residents and solicited their responses. The next day, the answer and discussion were sent out along with the next question. The round was presented each weekday of the academic year for 3 years. Over this longer term, the residents responded less frequently (the average daily participation rate for the first year of the round was 23% and declined in subsequent years). Interestingly, the residents were nonetheless enthusiastic about the round, preferring it to Grand Rounds and their Resident Lecture Series. We used e-mail to improve an existing teaching activity, namely a mock code teaching round. The mock code is a well-established teaching activity that is thought to effectively teach cognitive, attitudinal, and psychomotor aspects of leading the resuscitation of a critically ill patient (1). Logistical obstacles, including relatively few ED rotations, call obligations, and remote rotations, preclude the residents from attending every mock code. We postulated that an e-mail summary and discussion of the week’s mock code could provide a minimum of uniform cognitive instruction for those who were unable to attend (often the majority) and would augment the learning experience for those who had attended. We were pleased with the results of the e-mail round. All but two of our residents participated. The participants reported reading the vast majority of the e-mails and attributed almost half of their learning from the round as a whole, to the e-mails. This suggests that e-mail can compensate for scheduling difficulties. In addition, a
E-mail Amplification of Mock Codes
majority of the residents stored the e-mails and occasionally referred to them later. We had the impression that the three e-mails per week entitled “Mock Code” had a positive effect on both round attendance and the residents’ general attitude toward the round. The e-mails reinforced the principle that the mock code was for all residents and not just those on rotation in the ED. Another positive aspect of the round was its perceived efficiency for both the teacher and learner. The round leader was able to send the e-mails from his home. The residents were able to read them at times convenient to them. Textual information delivered by e-mail cannot replace the simulation of a code experience by an experienced clinician-educator. This is especially true for affective and psychomotor learning points. The fact that many residents reported learning more from the e-mail round than from the mock code itself likely reflects the fixed scheduling difficulties experienced by our pediatric residents. It is a formidable logistic challenge to ensure weekly pediatric resident attendance at an Emergency Medicine teaching round for the full academic year. However, even if the scheduling difficulties could be resolved, e-mails would likely still be an efficient supplement. With little instructor effort, they would reinforce teaching points made at the mock code. We noted that even residents who attended 75–95% of the rounds reported significant (25%) learning from the e-mails. Our round had essentially two parts: an e-mail summary of what took place at the mock code and a related e-mail discussion. The residents clearly attributed more of their learning to the e-mail summary of the mock code case than to the e-mail discussion point. This is surprising, because one would think that one of e-mail’s key educational features is the capacity for bi-directional communication. One possible explanation is that the summary e-mail provided those who were able to attend the mock code an opportunity to reflect on what they had learned. This is an essential component of adult learning that is often sacrificed to time-pressures (5). Other possible reasons why the discussion point was less popular than the summary may include: the inefficiency of reading possible wrong answers from fellow residents, the domination of the discussion by relatively few residents, lack of time to personally participate in the discussion, and questions of anonymity. Our finding supports that of Komorowski who, after 3 years of steadily decreasing resident responses, has eliminated this feature of her round (2). However, we still believe there is benefit to the discussion point since our residents attributed fully 19% of their total learning from the entire round to the discussion e-mails. That e-mail discussions can be of benefit even though relatively few actively participate is supported by the
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“lurking” behavior of the majority of e-mail listserv subscribers. Steele described the usage of the ped-em-l listserv that allows PEM practitioners to communicate widely among themselves (6). He found that, of the 1112 subscribers of the listserv, only 4% regularly contributed. This may result in an unbalanced discussion dominated by a few vocal members. In an unmoderated listserv, this goes unchecked. In a local e-mail discussion group such as the one described, an active, visible round leader can ensure a balanced learning experience. Ours is clearly only an exploratory study. We have not provided objective evidence of improved learning outcomes. While we surveyed the attitudes of almost all of our residents, our program is small. The results may not be generalizeable to other institutions; however, we feel that the idea is sufficiently compelling and easily implemented that other residency programs would do well to experiment with it. At the time of this round, ours was the only division within the hospital to use this novel form of teaching. Since resident time for reading e-mail is not limitless, the round might not be as effective if other subspecialties also held similar rounds. More sophisticated e-mail instructional tools are available. We used a simple text-based format but the incorporation of multi-media, including graphics, sound and video, into e-mail is possible (7). In addition, software environments such as WebCT (WebCT Inc, Peabody Massachusetts) and Learning Space (Lotus Development Corporation, Cambridge, Massachusetts) allow for archiving of e-mails, exchange of files, multiplechoice testing, tracking of student activity, and numerous other functions. Web sites such as www.e-circles.com and www.yahoo.com offer increasingly sophisticated electronic bulletin boards and chat functions. How much these added functions could contribute to resident learning should be explored. In summary, e-mail can be used to amplify resident learning from a traditional round. It is an efficient form of teaching that is popular with residents. The best format for e-mail discussion remains to be defined. We encourage other centers to experiment with this and other forms of e-mail teaching.
Acknowledgments—The authors wish to thank the IWK-Grace pediatric residents for their cheerful participation in the mock code round. We also wish to thank Dr. Terry Gandell for her helpful review of the manuscript.
REFERENCES 1. Roback MG, Teach SJ, First LR, Fleisher GR. Handbook of Pediatric Mock Codes. St. Louis: Mosby-Year Book Inc; 1998.
314 2. Komoroski EM. Use of e-mail to teach residents pediatric emergency medicine. Arch PediatrAdoles Med 1998;152:1141– 6. 3. Pusic MV. Pediatric residents: are they ready to use computeraided instruction? Arch PediatrAdoles Med 1998;152:494 – 8. 4. Letterie GS, Morgenstern LL, Johnson L. The role of an electronic mail system in the educational strategies of a residency in obstetrics and gynecology. Obstet Gynecol 1994;84:137–9.
M. V. Pusic and B. W. Taylor 5. Burge EJ. Learning in computer conferenced contexts: the learners’ perspective. J Distance Education 1991;9:19 – 43. 6. Steele DW. Ped-Em-L: An Internet Discussion List for Pediatric Emergency Medicine. 38th Annual Meeting of the Ambulatory Pediatrics Association 1998; Abstract Number 350. 7. Plain SW. The client side of E-mail. PC Magazine 1998;17:111– 56.