Alternatives to the Conference Status Quo - Wiley Online Library

Alternatives to the Conference Status Quo: Summary Recommendations from the 2008 CORD Academic Assembly Conference Alternatives Workgroup Annie T. Sadosty, MD, Deepi G. Goyal, MD, H. Gene Hern Jr, MS, MD, Barbara J. Kilian, MD, and Michael S. Beeson, MD

Abstract Objective: A panel of Council of Emergency Medicine Residency Directors (CORD) members was asked to examine and make recommendations regarding the existing Accreditation Council of Graduate Medical Education (ACGME) EM Program Requirements pertaining to educational conferences, identified best practices, and recommended revisions as appropriate. Methods: Using quasi-Delphi technique, 30 emergency medicine (EM) residency program directors and faculty examined existing requirements. Findings were presented to the CORD members attending the 2008 CORD Academic Assembly, and disseminated to the broader membership through the CORD e-mail list server. Results: The following four ACGME EM Program Requirements were examined, and recommendations made: 1. The 5 hours ⁄ week conference requirement: For fully accredited programs in good standing, outcomes should be driving how programs allocate and mandate educational time. Maintain the 5 hours ⁄ week conference requirement for new programs, programs with provisional accreditation, programs in difficult political environs, and those with short accreditation cycles. If the program requirements must retain a minimum hours ⁄ week reference, future requirements should take into account varying program lengths (3 versus 4 years). 2. The 70% attendance requirement: Develop a new requirement that allows programs more flexibility to customize according to local resources, individual residency needs, and individual resident needs. 3. The requirement for synchronous versus asynchronous learning: Synchronous and asynchronous learning activities have advantages and disadvantages. The ideal curriculum capitalizes on the strengths of each through a deliberate mixture of each. 4. Educationally justified innovations: Transition from process-based program requirements to outcomes-based requirements. Conclusions: The conference requirements that were logical and helpful years ago may not be logical or helpful now. Technologies available to educators have changed, the amount of material to cover has grown, and online on-demand education has grown even more. We believe that flexibility is needed to customize EM education to suit individual resident and individual program needs, to capitalize on regional and national resources when local resources are limited, to innovate, and to analyze and evaluate interventions with an eye toward outcomes. ACADEMIC EMERGENCY MEDICINE 2009; 16:S25–S31 ª 2009 by the Society for Academic Emergency Medicine Keywords: CORD, conference, emergency medicine

From the Department of Emergency Medicine, Mayo Clinic College of Medicine, (AS, DG) Rochester, MN; Department of Emergency Medicine, Alameda County – Highland, (HGH) Oakland, CA; Department of Emergency Medicine, University of California San Francisco, (BJK) San Francisco, CA; Department of Emergency Medicine, Summa Health System, (MSB) Akron, OH. Received May 8, 2009; revision received July 8, 2009; accepted July 12, 2009. Presented at the 2008 CORD Academic Assembly, March 2, 2008, New Orleans, LA. Address for correspondence: Annie T. Sadosty, MD; e-mail: [email protected]. The authors declare no conflicts of interest.

ª 2009 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2009.00588.x

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ALTERNATIVES TO THE CONFERENCE STATUS QUO

INTRODUCTION

METHODOLOGY

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Using quasi-Delphi technique, 30 EM residency program directors and faculty examined existing ACGME EM program requirements pertaining to conference, recommended revisions to the requirements as appropriate, and where possible, identified best practices. The workgroup examined four aspects of the RRC-EM conference requirements:

he Council of Emergency Medicine Residency Directors (CORD), in partnership with the Residency Review Committee for Emergency Medicine (RRC-EM), requested that a panel of CORD members lead a workgroup on Conference Alternatives at the Best Practices track of the 2008 CORD Academic Assembly. Following an information session wherein current requirements were reviewed, a subsequent breakout session ensued, and participants examined existing conference requirements and recommended revisions, as appropriate. The workgroup also sought to identify best practices pertaining to didactic education. Background The program requirements for emergency medicine (EM) stipulate that programs must: 1) offer residents an average of at least 5 hours ⁄ week of planned educational experiences developed by the EM training program; 2) ensure that residents are relieved of their clinical duties to attend these planned experiences. The program should ensure that residents attend on average 70% of the offerings.1 Accredited, allopathic EM training programs vary in length from 3 to 4 years. The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for EM training programs do not vary according to type of program (3- vs. 4-year). The Program Requirements further elaborate that alternative methods of education, such as interactive teleconferencing, would be considered with ‘‘appropriate educational justification,’’ but does not define what that entails.1 When questioned regarding acceptable alternatives, members of the RRC-EM emphasized the importance of learner and teacher interaction in said didactic offerings and cited dual goals of optimizing education and protecting the educational mission. Similarly, the 5 hour ⁄ week and 70% attendance rules were derived in the early era of EM training as a means of protecting the educational mission of the new training programs.2 As Phase 3 of the ACGME Outcome Project3 has taken hold, educators have become increasingly familiar with and accountable to educational outcomes. As such, programs have been evolving away from process-related requirements toward attestation of learner and programmatic outcomes. Proof of teaching no longer suffices. Programs now must measure learning. Additionally, just as the educational expectations have advanced, so too have educational technologies. As educators began to see the potential of new educational adjuncts in the context of the new outcomes era, some began questioning existing EM program requirements pertaining to conference. The final section of the EM program requirements invites programs to experiment and innovate collaboratively with the RRC-EM. These converging opportunities for simultaneous reexamination of current requirements and innovation led to the development of the workgroup.

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The 5 hours ⁄ week requirement The 70% attendance requirement The requirement for synchronous (group formatted learning) versus asynchronous (individualized learning, away from small or large groups of similar level learners) learning Educationally justified innovations

Thirty participants were divided into the above four sub-groups, and experienced EM educators moderated discussions. Mid-session, sub-group participants rotated en masse to a new topic moderator to gain a fresh perspective on the topic. Moderators summarized the sub-groups’ discussions to the entire workgroup for their commentary and edits. Thereafter, in a separate session, the workgroup findings were presented to the CORD members attending the 2008 CORD Academic Assembly for their feedback and later disseminated to the broader membership through the CORD mailing list server. Encapsulated summaries of the topics are included below. Challenging the Status Quo 5 hours ⁄ week minimum Summary of discussion: While understanding the historical rationale for the 5 hour ⁄ week requirement, EM residencies with established educational commitment find the current requirement more of a hindrance than a help. It emphasizes process over outcomes and mandates quantity, potentially at the expense of quality. Additionally, the hour ⁄ week requirement influences format and may not encourage programs to explore non-didactic options. That said, meeting participants broadly acknowledged that, for new programs and programs in difficult political climates, rules that define boundaries are often essential. Relevant literature: In 1997, Gillen showed that implementation of (not attendance at) a structured board review influenced first-year EM resident scores but did not favorably influence upper-level resident performance on the American Board of Emergency Medicine (ABEM) in-training examination (ITE).4 The process of implementing weekly reading assignments followed by multiple-choice quizzes and post-quiz reviews led to sustained improvement on the ITE scores in a surgical residency.5 Similarly, weekly didactic meetings with faculty followed by question-and-answer sessions and monthly tests resulted in better ITE performance than for historical controls in another surgical training program.6 Performance on a standardized examination measures test-taking skills and the ACGME competency of medical knowledge. No study has directly evaluated whether EM resident conference attendance influences performance on the EM ITE or the ABEM Qualifying

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Examination. In other specialties, the effect of resident conference attendance on performance on the specialty’s ITE or board certification written examination has been variable.7–10 In graduate medical education (GME), interactive teaching techniques, such as didactic conferences, coupled with the use of an audience response system have been shown to increase learning and retention.11 Work in the field of continuing medical education (CME) has shown that CME activities can improve physician knowledge and that multimedia interventions using multiple instructional techniques are preferred.12,13 For retention and knowledge application, repeated exposures are preferred to single ones.14 Studies involving conferences and outcomes pertaining to the other ACGME competencies are limited. In a study on behaviors of highly professional residents, Reed and colleagues showed that there was no association between internal medicine resident conference attendance and degree of professionalism.15 Nadel et al. showed that residents exposed to a multifaceted pediatric resuscitation workshop had improvements in scores measuring knowledge, skills, confidence, and leadership.16 Furthermore, a systematic review of randomized controlled trials evaluating methods for improving the quality of interpersonal care in primary care revealed that brief training sessions were not effective.17 In a systematic review of the effect of CME strategies, Davis and colleagues concluded that ‘‘relatively short (1 day or less) formal CME events such as conferences generally effected no change’’ on physician performance and health care outcomes.18 Interactive techniques such as those involving case-based discussions, role play, and hands-on participation were found to be more effective than the traditional CME lecture forum.18 Whether research in CME can be generalized to GME is unclear.

• 3-year program @ 48 weeks of conference offerings ⁄ year = 144 weeks x 5 hours ⁄ week = 720 hours ﬁ @ 70% attendance = 504 hours for post-graduate year (PGY) 1–3 or PGY 2–4 EM residency. • 4-year program @ 48 weeks of conference offerings ⁄ year = 192 weeks x 5 hours ⁄ week = 960 hours ﬁ @ 70% attendance = 672 hours for PGY 1–4 EM residency Based on the above, current conference requirements imply that it takes a minimum of 504 hours to teach The Model of Clinical Practice of Emergency Medicine (the Model).19 Therefore, if conference minimums must be defined, and 504 hours of exposure to the Model is the minimum, then 4-year programs should have a different hour ⁄ week requirement than 3-year programs, acknowledging fully that some programs of either length may choose to exceed their defined minimums. 70% attendance Summary of discussion: The program requirements stipulate that residencies must maintain a 70% resident attendance rate. Politically, this assists program leadership in justifying educational protected time to intra- and extra-departmental audiences and, occasionally, to residents with performance concerns. From an educational perspective, although the 70% requirement is one step toward ensuring broad exposure to the Model, it does not ensure exposure or mastery. Some non-Model benefits of the 70% attendance requirement include informal peer mentoring and support, development of a sense of residency community, and inter-departmental relationship building (in the case of joint conferences). The CME literature suggests that interactions between members of groups can influence individuals’ learning and change practice patterns.18 Several concerns emerged: 1.

Recommendations • Outcomes, not processes, should be driving how we mandate and use educational time. Programs that can demonstrate effective learning using models other than the standard 5 hours ⁄ week of didactics should be given latitude to do so. • Consideration should be given to requiring 5 hours ⁄ week only for new programs, programs with provisional accreditation, programs in difficult political environs, and programs with short accreditation cycles. This would allow defined programmatic outcomes to dictate conference requirements (e.g., poor standardized testing scores as a potential reflection of the curriculum, frequent emergency department–based duty hours violations as a reflection of under-resourced environment). • If the program requirements must retain a minimum hour ⁄ week reference, the hour ⁄ week requirement should vary according to type of program (3 vs. 4 year). The mathematical modeling below assumes 4 weeks of vacation yearly. Mathematical modeling:

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Curricular: Rigid attendance requirements have the potential to threaten curricular potential as programs avoid or eliminate valuable but rigorous rotations to ensure compliance with 70% average. Faced with the potential of lowering their own attendance rates, residents may avoid rigorous or away electives. Professionalism: Should we really be teaching residents to go to conference instead of intensive care unit rounds when post-call? Safety: The requirement forces residents who are post-call or post-night shift to attend conference. The requirement stands to jeopardize residents’ safety as they attempt to drive home sleepy or turn to stimulant use to stay awake.20,21

Relevant literature: First introduced by Knowles, adult learning theory suggests that adults are self-directed in planning and evaluating their learning, have a problem-solving approach to learning, learn best what is relevant and useful, and learn through experience.22 Few programs involve residents in the process of planning how the program deploys the Model, and many of the conference hours are not experiential. Moreover, learning styles vary across learners, which affects how residents learn.23–25 Individualized educational plans benefit learners of all type.

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Recommendations • Develop a requirement that affords programs flexibility to customize according to: 1.

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Local resources. Programs without a toxicologist, for example, should be allowed to capitalize on the expertise of a non-affiliated toxicologist by allowing residents to attend conferences at the poison center. Currently, conferences must be developed by the program to count toward the conference requirement. Individual residency needs. In Phase 3 of the Outcome project, data should be driving residency improvement efforts. Programs generating suboptimal performance on standardized tests might choose to replace traditional conference hours with 70% attendance being tracked with study groups or other forms of active learning that would be deployed in a non-group setting. Individual resident needs. A flexible requirement could allow programs to identify residents with similar learning styles and direct them toward optimal media for their learning without concern for the 70% attendance rate. Similarly, residents who truly learn best by reading might best use the core curriculum time by mapping out a reading plan and reading. With flexibility, the potential to allow residents to customize their own learning by developing their own plan with a keen self-awareness for what is useful to them exists.

• If attendance minimums must be defined, consideration for a criterion minimum of hours ⁄ year per resident should be given to enhance flexibility and customization. • To preserve some of the non-Model benefits of core attendance, the RRC-EM could track attendance rates for certain conferences that are optimally delivered in a large forum (e.g., grand rounds, morbidity and mortality). Synchronous versus asynchronous learning Summary of discussion: For purposes of this discussion, synchronous learning is defined as learning that occurs in large- or small-group formats. Synchronous learning encompasses the traditional approaches to conferences, where all residents are asked to attend and topics are presented at one time. Asynchronous learning is

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defined as individualized learning, away from small or large groups of similar-level learners. Table 1 outlines activities best suited for synchronous and asynchronous deliveries. Relevant literature: The boundaries between synchronous and asynchronous learning activities have become blurred as new technologies have attempted to blend synchronous learning with videoconferences, teleconferences, web-based learning, etc.26–30 A synchronous learning activity (SLA) allows for important or time-critical topics to be presented to a large group. Moreover, attendance at an SLA is easily tracked, making bookkeeping simple. Additionally, SLAs such as residency retreats can be used as teambuilding activities. Beyond the retreat setting, the CME literature has shown that there is inherent value in having participants gather together.18 Ideas can be exchanged in real time with the potential for immediate feedback and identification of salient teaching points. Additionally, there is value to modeling behavior of faculty and resident leaders to the rest of the residents.31 Role models can display examples of professionalism and demonstrate masterful didactic delivery techniques to a broad audience. Conversely, asynchronous learning uniquely allows a teacher to identify the needs of an individual learner (e.g., a resident who struggles with x-ray interpretation) and to identify or develop asynchronous learning activities (ALAs; e.g., independent review of radiology teaching cases) that address those needs.32,33 The recent Macy Report on continuing education in the health professions emphasizes the need for physicians to examine and improve their own practices.34 The ACGME requires that programs teach residents skills for lifelong learning. Asynchronous learning affords programs an opportunity to teach residents how to direct their own learning. Because of varied learning styles, SLAs are not customizable to all learners in the audience. The variability of EM schedules makes synchronous attendance challenging. Perfect attendance at large-group conferences can rarely be achieved. Physicians working clinically during the time of the conference cannot attend; those following a night shift might attend but may not learn because of fatigue.35 Asynchronous learning activities allow learners with varied schedules to participate when it is safe, when they are able, and when they are more ready to learn. Given the scheduling challenges facing the specialty of EM, ALAs can ensure that all

Table 1 Synchronous Versus Asynchronous Activities

Synchronous learning activities allow for immediate feedback and interactions or options, which may enhance learning. Best suited for sessions such as: • Case-based discussions (interesting conferences, morbidity and mortality) • Combined special conferences • Traditional journal clubs • Ethical discussions • Discussion of clinical practice variations • Procedure laboratories

Asynchronous learning allows for individualized learning and practice improvement at the learner’s pace and timetable. Best suited for sessions such as: • Policies and procedures • Regulatory updates (Joint Commission, infection control) • Uniformly required curricular topics


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residents have exposure to a particular topic or series of topics. The core content of the specialty might be nicely suited to asynchronous delivery. Idea exchange can occur through ALAs such as blogs and wikis.36,37 Asynchronous learning activities may be beneficial to individual residencies in other ways. The Model is vast. It is unrealistic to expect that core faculty at an individual residency would have expertise in each of the topic areas, but collectively, among all EM residencies, expertise in each of these topics exists. Asynchronous learning would allow programs to enlist recognized experts in a given content area and provide expertise to residencies where no or limited expertise exists. Asynchronous learning activities are more difficult to track than SLAs. With less social interaction, fewer opportunities for behavioral modeling exist. Asynchronous activities require considerable effort to develop and maintain. Those with quiz verification of participation can be abused as learners can skip ahead to the quiz without participating in the learning activity. New technologies, as well as recognition of the value of ‘‘older’’ technologies, such as textbooks, have placed pressure on medical educators to recognize ALAs as a viable method of education. Some learning activities are better suited for large- or small-group presentation and participation, although for some educational activities, the distinct benefit of one form over the other is blurred. Recommendations • A deliberate mixture of SLAs and ALAs is ideal. • Research is needed to clearly define those educational activities that benefit from one type of learning over the other. Educationally justified innovations Summary of discussion: Together, technology advancements, curricular enhancements, and the ACGME Outcome Project are driving educational innovation. Technology has opened the doors to the potential for innovations in synchronous learning, with traditional lecture-based learning now exportable and portable through podcast and web-based technologies. Additionally, screen-based and high-fidelity simulation allow for other asynchronous learning opportunities.38 Some programs have innovated to achieve educational goals. Technology has driven some of these advances. Relevant literature: Mahadevan and colleagues used web-based streaming video to deliver a rotational orientation curriculum to residents rotating through the emergency department.39 Ashton and Bhati described successful implementation of an asynchronous learning network in Australia.40 In this network, senior house officers in EM worked through online tasks and posted their responses for peer review and discussion. In the United Kingdom, a virtual learning environment was used to educate residents in EM.41 The majority of EM residency programs use some form of simulation training.42 Some EM training programs deliver significant percentages of their conference time through simulation and report that residents rate simulation-based sessions higher than lectures.43,44

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McLaughlin published a review of simulation in GME from the vantage point of EM.38 Suffice it to say, simulation has been used to teach diverse content: procedural skills,45–47 systems-based practice and teamwork,48,49 cognitive expertise,50 morbidity and mortality,51 and medical malpractice.52 Other innovations are not technology driven. Aligned with adult learning theory, programs have initiated knowledge translation shifts—clinical shifts with a focus on real-time, need-to-know, knowledge acquisition, dissemination, and translation.53 Modular curricula based on PGY of training and associated learner needs have been implemented. Similarly, some residencies have initiated individualized learner tracks wherein residents achieve niche expertise through concentrated self-study or through a residency-designed curriculum. In outcomes-based education, some EM educators have suggested moving toward a Model-based mastery construct. Under this proposed construct, once a resident mastered the Model, no further core content didactic attendance would be required for that learner, but until the requirements change, this will be impossible. Despite the above innovations, few have outcomes attached. Like much of education, few data exist to guide reform. As we approach Phase 4 of the ACGME Outcome Project, we must begin to assess educational outcomes in an effort to identify benchmark programs and practices. The program requirements should reflect what is needed to achieve excellent outcomes. Educational research is challenging and necessary. Historically, career educators have been focused on teaching, and the science of teaching has lagged, in part because the work of teaching simultaneously inspires and exhausts the educator. For most career educators, it is impossible to layer educational research onto existing teaching and administrative requirements. To reach Phase 4, we must free up the educational genius to innovate in this arena. Recommendations • Eliminate process-based program requirements pertaining to conference. • Transition to outcomes-based requirements.

CONCLUSIONS The ACGME, the RRC-EM, and EM educators clearly desire the best resident education possible. Our goals are aligned. We desire the same outcomes—great programs that produce competent and independent physicians—but the requirements that were logical and helpful years ago may not be logical or helpful now. Since the early days of the RRC-EM requirements, technologies available to educators have changed, the Model has grown, and online on-demand education has grown even more. Moreover, EM’s presence within the greater medical system has solidified. As we aspire to take EM GME forward, we need more flexibility—flexibility to customize EM education to suit individual resident and individual program needs, flexibility to capitalize on regional and national resources when local resources are limited, flexibility to

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innovate (without being simultaneously exhausted by process requirements), and flexibility to analyze and evaluate interventions with an eye toward outcomes.

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The authors would like to thank the leadership of CORD for their trust and the participants of the Conference Alternatives workgroup for their passionate, measured, and inspiring contributions.

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