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An Innovative Adult-Learning Curriculum Merging Evidence-Based Medicine, Knowledge Translation, and Research Design
Research Forum Abstracts Table. Median VAS Change Associated with CYP2D6 Drug Use, only patients with 2 serial VAS measurem
Administered Drug Oxycodone, (IQR [range]) Hydrocodone (IQR [range]) Ondansetron (IQR [range])
Median Delta VAS Change All Patients
Median Delta VAS Change Patients with CYP2D6 Drug Score ‡0
Median Delta VAS Change Patients with CYP2D6 Drug Score ‡1
Wilcoxon Rank Sums p value between CYP2D6 drug groups
21(4.5, 37.5 [ 12-89]) 20(1, 33 [ 10-82]) 26(9, 45.5 [ 35-91])
22.5(9, 41.25 [ 10-89]) 29.5(5.25, 42.75 [ 3-82]) 21(5, 33 [ 33-65])
19(3, 32 [ 12-82]) 13(0, 29 [ 10-65]) 32.5(19.75, 56.75 [ 35-91])
0.127 0.014* 0.006*
* statistically significant
TF-2
An Innovative Adult-Learning Curriculum Merging Evidence-Based Medicine, Knowledge Translation, and Research Design
Hess J, Siegelman J, Lamm R, Moll J/Emory University, Atlanta, GA; University of Michigan, Ann Arbor, MI
Study Objectives: Emergency physicians are adult learners who must continually update their practice based on regular evaluation of the medical literature. Over the course of their careers, many also oversee implementation of evidence-based practice changes and evaluate the impacts of these interventions. Basic research methods and fundamentals of evidence-based medicine (EBM) are standard components of EM residency curricula, and knowledge translation (KT), the process of integrating new evidence-based findings into practice, is increasingly being taught as well. While the topics are related, there is no model curriculum that integrates the three or that combines didactic approaches with applied approaches based on key principles of adult learning. Methods: We developed and implemented a three-year EM residency curriculum that integrates EBM principles, a standard model of KT, and basic research design principles. Its goals are: 1) to improve residents’ ability to practice EBM by accessing, querying, and assessing relevant literature using the PICO (population, intervention, comparison, outcome) framework; 2) to improve residents’ capacity to design and carry out KT of innovations identified through their EBM activities; and 3) to improve residents’ research design capacity by formulating study protocols to evaluate the effect of KT interventions. Teaching methods are a mixture of didactic, small-group, and asynchronous learning. Learners cover basic principles in their first year. In the second they break into three groups, each of which identifies, outlines, and advocates a possible practice change, specifying both an approach to KT and to evaluating the change’s impacts. The groups present their findings to each other and the faculty and one KT intervention is chosen for implementation and study. In the third year, the residents implement the chosen intervention and protocols for evaluating its impacts. The curriculum will be evaluated using narrative evaluations and process measures. Results: The first resident cohort exposed to the curriculum is now entering its third year. Narrative evaluations of the didactic portion of the curriculum were strongly positive. Residents identified three candidate interventions: doubling the d-dimer threshold for ordering a CT-angiogram in patients being evaluated for PE; systematic use of video laryngoscopy in intubation of patients in c-spine immobilization; and elimination of 24-hour observation and repeat CT in anticoagulated patients with closed head injury and no deficits. Residents and faculty chose the d-dimer intervention for implementation. The residents are now implementing the intervention and initiating prospective studies of the intervention’s impact on physician practice and patient outcomes. Conclusions: EBM, research design, and KT are related topics that are well suited for an integrated, applied curricular component in EM residency. At this preliminary stage, the intervention has been well received and learners have achieved intended curricular milestones. The curriculum has resulted in a systematic intervention to translate recent evidence into practice change in our institution and in a systematic, well-designed effort to evaluate the impacts of the intervention on physician practice and patient outcomes.
TF-3
Teaching to Teach: Techniques for Teaching in a Busy Emergency Department
Brown S, Bush C/Spectrum Health Butterworth Hospital, Grand Rapids, MI
Study Objectives: To evaluate a new type of instructional module designed to give residents and faculty members the tools necessary to effectively teach junior residents and medical students during emergency department (ED) shifts, and to improve linear teaching techniques. A secondary goal was to assess the current practice of teaching in the ED from both resident and faculty perspectives.
Volume 62, no. 4s : October 2013
Methods: This prospective qualitative study involved residents and faculty from a single ACGME-accredited 3-year emergency medicine residency. The instructional module was presented as a five-part miniseries of lectures and small group role-playing and discussion, as well as fishbowl group evaluation. Techniques discussed included the RIME (Reporter, Interpreter, Manager, Educator) model of learning, SPIT (Serious, Probable, Interesting, Treatable) differentials, cognitive apprenticeship, microskills toolbox, and effective feedback. Outcome measures included pre- and post-module surveys sent to learners asking them to indicate the effectiveness and frequency of bedside teaching in the ED, as well as to faculty to assess comfort level with bedside teaching and how often it is performed. Similar surveys were sent out two weeks prior to the teaching module and four weeks following its conclusions. Descriptive statistics (95% confidence intervals) and frequency tables were used to describe data. We hypothesized the teaching series would increase the frequency of teaching and feedback provision in the ED. Results: Twenty-five residents and 41 faculty members responded to the premodule survey. Overall, residents felt that teaching occurred in 21-40% of cases in the ED, lasting for less than 5 minutes at a time. Teaching was felt to be moderately effective and usually occurred in the form of expansion of the differential diagnosis. Feedback was given immediately following <20% of shifts. Faculty report teaching was most often in the form of background explanation. Faculty felt that they provided feedback more often than residents perceived it, were more likely to provide feedback if first asked by a resident, and were more likely to provide negative feedback in written form. In the post-module survey, residents felt teaching occurred in cases more frequently (in 41-60% of cases) and that feedback was provided more often (after 21-40% of shifts). Background explanation of conditions was the most common method of teaching in the second survey compared to expansion of differential diagnosis prior. Their most frequently used technique was SPIT differential. Faculty members in the post-module survey felt they taught more frequently (in 21-40% of cases) and provided feedback more often (after 21-60% of shifts). This feedback was even more likely to be provided if residents asked for it compared to prior. Background explanation continued to be the most common method of teaching. Conclusions: There is an opportunity to improve techniques for teaching residents and students in the ED, but techniques must be quick and applicable enough to be used in 5-minute increments or less. Residents and faculty agree that teaching is currently moderately effective, but differ in the frequency and type of which they perceive teaching to occur. Feedback remains a challenge for both residents and faculty members.
TF-4
Asynchronous E-Learning Web Site for Off-Service Residents Rotating in the Emergency Department
Williams SR/Stanford University, Stanford, CA
Study Objectives: This study aims to 1) identify key content to optimize off-service resident learning in the emergency department (ED) and 2) explore the feasibility of an asynchronous learning Web site-based curriculum to address these key content areas. The ED rotation has the potential to provide an excellent educational opportunity for rotating “off-service” residents from several specialties, including internal medicine and surgery. However, review of the literature reveals minimal research on optimal education practices and curriculum design for off-service residents in the ED, especially since the increased utilization of Web-based instructional tools. Off-service residents are a challenging group for whom to design a curriculum. They represent an extremely heterogeneous population with widely varying backgrounds, levels of comfort with sick patients, and workflow patterns. In addition,
Annals of Emergency Medicine S159
Administered Drug Oxycodone, (IQR [range]) Hydrocodone (IQR [range]) Ondansetron (IQR [range])
Median Delta VAS Change All Patients
Median Delta VAS Change Patients with CYP2D6 Drug Score ‡0
Median Delta VAS Change Patients with CYP2D6 Drug Score ‡1
Wilcoxon Rank Sums p value between CYP2D6 drug groups
21(4.5, 37.5 [ 12-89]) 20(1, 33 [ 10-82]) 26(9, 45.5 [ 35-91])
22.5(9, 41.25 [ 10-89]) 29.5(5.25, 42.75 [ 3-82]) 21(5, 33 [ 33-65])
19(3, 32 [ 12-82]) 13(0, 29 [ 10-65]) 32.5(19.75, 56.75 [ 35-91])
0.127 0.014* 0.006*
* statistically significant
TF-2
An Innovative Adult-Learning Curriculum Merging Evidence-Based Medicine, Knowledge Translation, and Research Design
Hess J, Siegelman J, Lamm R, Moll J/Emory University, Atlanta, GA; University of Michigan, Ann Arbor, MI
Study Objectives: Emergency physicians are adult learners who must continually update their practice based on regular evaluation of the medical literature. Over the course of their careers, many also oversee implementation of evidence-based practice changes and evaluate the impacts of these interventions. Basic research methods and fundamentals of evidence-based medicine (EBM) are standard components of EM residency curricula, and knowledge translation (KT), the process of integrating new evidence-based findings into practice, is increasingly being taught as well. While the topics are related, there is no model curriculum that integrates the three or that combines didactic approaches with applied approaches based on key principles of adult learning. Methods: We developed and implemented a three-year EM residency curriculum that integrates EBM principles, a standard model of KT, and basic research design principles. Its goals are: 1) to improve residents’ ability to practice EBM by accessing, querying, and assessing relevant literature using the PICO (population, intervention, comparison, outcome) framework; 2) to improve residents’ capacity to design and carry out KT of innovations identified through their EBM activities; and 3) to improve residents’ research design capacity by formulating study protocols to evaluate the effect of KT interventions. Teaching methods are a mixture of didactic, small-group, and asynchronous learning. Learners cover basic principles in their first year. In the second they break into three groups, each of which identifies, outlines, and advocates a possible practice change, specifying both an approach to KT and to evaluating the change’s impacts. The groups present their findings to each other and the faculty and one KT intervention is chosen for implementation and study. In the third year, the residents implement the chosen intervention and protocols for evaluating its impacts. The curriculum will be evaluated using narrative evaluations and process measures. Results: The first resident cohort exposed to the curriculum is now entering its third year. Narrative evaluations of the didactic portion of the curriculum were strongly positive. Residents identified three candidate interventions: doubling the d-dimer threshold for ordering a CT-angiogram in patients being evaluated for PE; systematic use of video laryngoscopy in intubation of patients in c-spine immobilization; and elimination of 24-hour observation and repeat CT in anticoagulated patients with closed head injury and no deficits. Residents and faculty chose the d-dimer intervention for implementation. The residents are now implementing the intervention and initiating prospective studies of the intervention’s impact on physician practice and patient outcomes. Conclusions: EBM, research design, and KT are related topics that are well suited for an integrated, applied curricular component in EM residency. At this preliminary stage, the intervention has been well received and learners have achieved intended curricular milestones. The curriculum has resulted in a systematic intervention to translate recent evidence into practice change in our institution and in a systematic, well-designed effort to evaluate the impacts of the intervention on physician practice and patient outcomes.
TF-3
Teaching to Teach: Techniques for Teaching in a Busy Emergency Department
Brown S, Bush C/Spectrum Health Butterworth Hospital, Grand Rapids, MI
Study Objectives: To evaluate a new type of instructional module designed to give residents and faculty members the tools necessary to effectively teach junior residents and medical students during emergency department (ED) shifts, and to improve linear teaching techniques. A secondary goal was to assess the current practice of teaching in the ED from both resident and faculty perspectives.
Volume 62, no. 4s : October 2013
Methods: This prospective qualitative study involved residents and faculty from a single ACGME-accredited 3-year emergency medicine residency. The instructional module was presented as a five-part miniseries of lectures and small group role-playing and discussion, as well as fishbowl group evaluation. Techniques discussed included the RIME (Reporter, Interpreter, Manager, Educator) model of learning, SPIT (Serious, Probable, Interesting, Treatable) differentials, cognitive apprenticeship, microskills toolbox, and effective feedback. Outcome measures included pre- and post-module surveys sent to learners asking them to indicate the effectiveness and frequency of bedside teaching in the ED, as well as to faculty to assess comfort level with bedside teaching and how often it is performed. Similar surveys were sent out two weeks prior to the teaching module and four weeks following its conclusions. Descriptive statistics (95% confidence intervals) and frequency tables were used to describe data. We hypothesized the teaching series would increase the frequency of teaching and feedback provision in the ED. Results: Twenty-five residents and 41 faculty members responded to the premodule survey. Overall, residents felt that teaching occurred in 21-40% of cases in the ED, lasting for less than 5 minutes at a time. Teaching was felt to be moderately effective and usually occurred in the form of expansion of the differential diagnosis. Feedback was given immediately following <20% of shifts. Faculty report teaching was most often in the form of background explanation. Faculty felt that they provided feedback more often than residents perceived it, were more likely to provide feedback if first asked by a resident, and were more likely to provide negative feedback in written form. In the post-module survey, residents felt teaching occurred in cases more frequently (in 41-60% of cases) and that feedback was provided more often (after 21-40% of shifts). Background explanation of conditions was the most common method of teaching in the second survey compared to expansion of differential diagnosis prior. Their most frequently used technique was SPIT differential. Faculty members in the post-module survey felt they taught more frequently (in 21-40% of cases) and provided feedback more often (after 21-60% of shifts). This feedback was even more likely to be provided if residents asked for it compared to prior. Background explanation continued to be the most common method of teaching. Conclusions: There is an opportunity to improve techniques for teaching residents and students in the ED, but techniques must be quick and applicable enough to be used in 5-minute increments or less. Residents and faculty agree that teaching is currently moderately effective, but differ in the frequency and type of which they perceive teaching to occur. Feedback remains a challenge for both residents and faculty members.
TF-4
Asynchronous E-Learning Web Site for Off-Service Residents Rotating in the Emergency Department
Williams SR/Stanford University, Stanford, CA
Study Objectives: This study aims to 1) identify key content to optimize off-service resident learning in the emergency department (ED) and 2) explore the feasibility of an asynchronous learning Web site-based curriculum to address these key content areas. The ED rotation has the potential to provide an excellent educational opportunity for rotating “off-service” residents from several specialties, including internal medicine and surgery. However, review of the literature reveals minimal research on optimal education practices and curriculum design for off-service residents in the ED, especially since the increased utilization of Web-based instructional tools. Off-service residents are a challenging group for whom to design a curriculum. They represent an extremely heterogeneous population with widely varying backgrounds, levels of comfort with sick patients, and workflow patterns. In addition,
Annals of Emergency Medicine S159