EDUCATION/RESIDENTS’ PERSPECTIVE
Integration of Social Media in Emergency Medicine Residency Curriculum Kevin R. Scott, MD*; Cindy H. Hsu, MD, PhD; Nicholas J. Johnson, MD; Mira Mamtani, MD; Lauren W. Conlon, MD; Francis J. DeRoos, MD *Corresponding Author. E-mail: [email protected], Twitter: @K_ScottMD. 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.05.030
[Ann Emerg Med. 2014;64:396-404.]
INTRODUCTION As education moves away from the age of pen and paper, the digital platform has become a rapidly growing resource for both emergency medicine educators and learners. Social media are any Internet-based applications that enable content sharing and rapid interactions between large populations. The growth and influence of social media technologies have allowed the distribution of ideas far beyond geographic borders.1 During the past decade, an estimated 141 blogs and 42 podcasts related to emergency medicine and critical care have been developed in 24 countries.2 Free open access meducation (FOAM), defined as a community of open access resources for learning in medicine, leverages the powerful sharing and interactive qualities of social media to rapidly disseminate educational materials and expert insights.3 Social media resources are being used frequently by emergency medicine training programs; a recent survey of 226 emergency medicine residents at 12 different residency programs showed that almost 98% use some form of social media for learning for at least 1 hour per week.4 Many emergency medicine residency programs across the United States and Canada have started their own Twitter accounts (Table), largely through the work of the group at Academic Life in Emergency Medicine (ALiEM).5 Despite the strong tendency to use social media for learning, there remains a lack of understanding or science of how to implement it effectively.6 Our primary goal is to describe the different social media modalities and how our program and others have created a presence in these platforms. We will also offer specific examples of how these modalities can be integrated asynchronously or in conjunction with didactic sessions. Last, we will highlight the potential struggles and barriers that may be associated with the implementation and integration of social media in residency education. We hope that this article will spark further discussion on social media use and inspire future studies to examine the effectiveness of its integration in emergency medicine residency curricula.
SOCIAL MEDIA MODALITIES Blogs Blogs are Web sites where individuals or groups can post material. They serve as useful ways for educators to compile and 396 Annals of Emergency Medicine
disseminate information. Popular blogs in emergency medicine education include ALiEM (http://www.academiclifeinem.com) and Life in the Fast Lane (http://www.lifeinthefastlane.com). Some emergency medicine training programs have created their own blogs that incorporate posts from faculty, fellows, and residents. SUNY Downstate’s The Original Kings of County (http://www.blog.clinicalmonster.com) includes frequent educational posts spanning the realms of trauma, toxicology, and critical care. In addition, they provide brief synopses of their program’s morning reports and journal clubs. The University of Maryland posts daily educational pearls (http://www.umem.org/ educational_pearls) that are available to anyone. In addition, the critical care fellows at the University of Maryland have created a blog dedicated to sharing content from their didactic curriculum to highlight controversial and cutting-edge topics in critical care (http://www.marylandccproject.org). Finally, the discussion of practice variability is one of the main themes behind a blog from New York University–Bellevue Hospital known as EM Lyceum (http://emlyceum.com). Blogs are useful ways for residency programs to rapidly and consistently disseminate educational content to their residents, and they also allow interaction and discussion among residency programs. Although blogs vary in their format, quality, and content, many of them enable residents to rapidly access concise, current, and referenced synopses of clinical and educational material that can be used for on-shift (“on-the-fly”) learning and can point them to relevant primary literature. Because emergency medicine is both science and art, a key component of residency training is learning from the experiences of others. Often, there is a dearth of experiential commentary in traditional learning resources such as journal articles and textbooks, but blogs allow this important information to be conveyed. Podcasts A podcast is composed of digitally recorded material that can be downloaded or streamed by users. They are typically audio files, but may be recorded in other formats as well. Podcasts have been used extensively by emergency physicians as ways to disseminate traditional lecture material to a multitude of learners. EMCrit (http://www.emcrit.org) is a great example of how one educator uses podcasts to share his knowledge with many more Volume 64, no. 4 : October 2014
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Table. Emergency medicine residency Twitter accounts in the United States and Canada. Program Baystate Health Beth Israel Medical Center Beth Israel Deaconess Medical Center Boston Medical Center Brooklyn Hospital Brown University Carolinas Medical Center Conemaugh Memorial Medical Center Dartmouth-Hitchcock Drexel University Duke University East Carolina University Emory University Genesys Regional Medical Center Grandview Medical Center Harbor-UCLA Medical Center Highland General Hospital Indiana University Jacobi/Montefiore Kaiser Permanente San Diego Kelowna General Hospital London Health Sciences Centre Long Island Jewish Medical Center Lincoln Medical and Mental Health Center Maimonides Medical Center Maricopa Medical Center Mayo Clinic McGill University McLaren Macomb Mount Sinai NYU/Bellevue
Twitter Handle
Program
Twitter Handle
@BaystateEM @BethIsraelEMED @BIDMCEM @BMCEmergency @bkhospital @BrownEMRes @CMCEM @ConemaughEMres @dartmouthem @DrexelEmergency @dukeemergency @ECU_EM @EmoryEM @GenesysEM @GrandviewEM @HarborUCLAEM @HGHED @IUEmergencyMed @Jacobi_EM @Sdmeded @FRCPMKelowna @emergencylondon @LIJ_EM @LincolnEM @Maimonides_EM @MaricopaEM @MayoClinicEM @mcgill_emerg @McLarenMacEM @SinaiEM @NYUEMChiefs
Olive View–UCLA Medical Center Oregon Health & Sciences University Parkland Memorial Hospital Queen’s University Regions Hospital Staten Island University Hospital Stanford/Kaiser St. Luke’s–Roosevelt St. Joseph’s Healthcare System SUNY Downstate/Kings County Hospital Center Temple University Texas A&M–Christus Spohn University of Alabama University of Arizona University of Arkansas University of California–Davis University of California–Irvine University of Chicago University of Cincinnati University of Illinois–Peoria University of Kentucky University of Maryland University of Missouri University of Nevada University of Ottawa University of Pennsylvania University of Texas at Houston Washington University WellSpan York Hospital Wright State University Yale University
@UCLAEMRes @OHSUEmergency @DallasEMed @Qemerg @regionsem @statenislandem @StanfordEMRes @SLREM @StJoesEM @kingsofcounty @TempleEM @CCEMRP @uabem @UAEMresidency @UAMSED @UCDEmergMed @UCIrvineEM @UChicagoEM @UCMorning Report @UICOMPEM @WildcatEMres @UMEmergencyMed @MizzouEM @LasVegasEM @emergmedottawa @UPennEM @UTEmergencyMed @WashUEM @WellSpanYHEMdoc @WrightStEM @yaleem2
learners than are typically reached with traditional lectures.7 EMCrit and other podcasts such as SMART EM (http://www. smartem.org) and EM Basic (http://www.embasic.org) are free, open-access resources that distribute lectures, interviews, and discussions about emergency medicine and critical care. Another podcast, although not open access, is EM:RAP (http://www. emrap.org), which is most popular among emergency medicine residents because it is provided as a free benefit with Emergency Medicine Resident Association membership.4 Our program has incorporated podcasts as adjuncts to our modular curriculum. Each month, residents are provided with a list of podcasts that are relevant to the core topics being covered during that period. The podcasts are selected by our residency leadership according to their quality and relevance to the modular block from multiple aforementioned resources.8-10 Residents are required to listen to the podcasts and answer online questions about the materials reviewed. This integration has allowed a portion of required learning to be completed when it is most convenient for the residents, as well as increased interactive discussions during weekly conference time. The residency program at Mount Sinai in New York has described a similar approach. Their residents are provided with optional instructive resources and asked to answer questions about the content.11 Similar to our program, such integration has Volume 64, no. 4 : October 2014
also replaced 1 hour of Mount Sinai’s formal conference time each week, allowing the residents to learn on their own time. Videocasts Videocasts are similar to podcasts, but as the name suggests, episodes are in a video format. Several studies have shown improved procedural techniques when residents are taught through videos and may be one of the most effective ways to integrate social media into emergency medicine resident education.12-14 They are especially useful for the demonstration of rarely performed procedures and the dissemination of visual content such as images and ECGs. Furthermore, videocasts can rapidly incorporate the expertise of educators from other hospitals into a residency’s curriculum without incurring substantial travel expenses and time. Examples of high-quality videocasts include Hennepin County Medical Center’s instructional videos on a variety of emergency medicine–related topics, including trauma, ECGs, and procedures (http://www.hqmeded.com). In addition, the University of Maryland also offers a series of instructional procedure videos, as well as videos for oral board preparation (http://www.umem.org/page/education/residency/video_ training). Finally, the Patwari Video Academy (http://www. academiclifeinem.com/category/clinical/patwari-videos) teaches Annals of Emergency Medicine 397
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Social Media and Emergency Medicine Residency Curriculum various core emergency medicine topics by using a whiteboard animation application combined with recorded audio. Twitter The use of the microblog Twitter has become a popular route for educators to share concise pearls and reference links to useful resources. Blogs, podcasts, and videocasts are powerful disseminators of information but may require significant time for the learners to participate. We believe that learners with demanding schedules crave educational pearls and relevant references that are pertinent to a particular topic. Bahner et al15 described the use of “push” technology to distribute educational pearls about point-of-care ultrasonography to the emergency medicine residents at Ohio State University through the Twitter handle @EDUltrasound. Push technology can be described as an Internet-based communication in which the platform provides information as it is made available rather than the user needing to “pull” or refresh information. A majority of followers of @EDUltrasound found the tweets to include useful information. In addition to individuals sharing their own educational snippets, emergency medicine residencies have embraced Twitter as a means to share pearls from weekly didactic sessions through the use of the #EMConf hashtag.16 “Tweeters” share and spread information from a learning session to other consumers. For example, our program has a Twitter account that is used primarily to share highlights from didactic sessions and simulations (http://www.twitter.com/UPennEM). The chief residents are responsible for selecting and then tweeting pearls from lectures, which has allowed our own residents who may be on off-service rotations to follow conferences asynchronously. In addition, individuals who worked the previous evening and are not present for all of conference time can review highlights from a given day’s didactics. Consumers of these tweets include not only our own residents but also hundreds more who have chosen to follow the account. Before the launch of the #EMConf hashtag, Twitter was used to disseminate content from regional and national conferences. Examples of these conferences included the 2013 regional Delaware Valley American Academy of Emergency Medicine conference (#DVAAEM13) in Philadelphia, 2013 Society for Academic Emergency Medicine annual meeting (#SAEM13) in Atlanta, and 2013 American College of Emergency Physicians (ACEP) Scientific Assembly (#ACEP13) in Seattle. Conference live tweeting has continued to increase in popularity, with an increase to 1,332 individual tweeters at the 2013 American College of Emergency Physicians Scientific Assembly from only 294 at the 2012 meeting.17 In 2013, the inaugural Social Media and Critical Care Conference took place in Australia. There were more than 16,000 total tweets that incorporated the hashtag #SMACC13, but of more significance was the innovative integration of social media into the conference.18 Sessions included Google Hangouts with speakers, live-streamed sessions, and recorded sessions with the purpose of eventually making them available through YouTube. Conference speakers could 398 Annals of Emergency Medicine
easily disseminate lecture pearls, and more important, learners who could not attend the conferences were able to follow the didactic sessions. Google Hangouts Google Hangouts is a free utility that allows multiuser video conferencing and messaging, and has potential to be a powerful tool for interactive education. This platform allows real-time discussion and learning without participants being at the same location. Recently, it has been used in combination with other social media modalities by ALiEM and Annals of Emergency Medicine to create a venue for a global journal club using the Twitter hashtags #ALiEMJC and #ALiEMRP. The ALiEM Web site first served as a forum for the discussion of several questions about a journal article during multiple days.19,20 Using Google Hangouts, learners were then able to directly ask the authors questions and discuss their interpretations of the article’s findings in real time. For example, the authors answered curated questions on the clinical decision rules for subarachnoid hemorrhage, post–cardiac arrest targeted temperature management, and the nuances of multiple mini interviews during residency recruitment.21-26 These global journal clubs and the discussion of the multiple mini interviews article demonstrated that the combination of different social media modalities creates innumerable opportunities for real-time discussion. We are unaware of any programs that have used this modality during their didactic sessions, but believe this may be another potential powerful tool for residency education.
FURTHER INTEGRATION Flipped Classroom With so many open access resources, learners can easily individualize their education according to their needs and interests. Integration of asynchronous, individualized learning with the classroom is the basis of what is known as the “flipped classroom.” The idea is that fundamental knowledge is gained by the individual learner on his or her own time, and the classroom becomes the setting to apply that knowledge. This educational model offers a unique venue for learners to discuss their “take aways” and interpretation of a podcast or blog. Our residency has integrated modified versions of the flipped classroom model, using social media in a few specific ways with a debate format and a discussion-based Tech Talk series. Through the debate format, senior residents and faculty participate in an evidence-based discussion about the clinical management of an acute disease process; an example would be rhythm versus rate control for atrial fibrillation. Before the debate, residents and faculty are sent several podcasts and articles chosen by the residency leadership that are related to the evidence available about a controversial topic. Additional literature review is conducted by the senior resident leading the discussion. A moderated debate then occurs during scheduled conference time involving faculty and residents. We believe that providing blog entries or podcasts for review before conference results in more Volume 64, no. 4 : October 2014
Scott et al participation during the asynchronous component and may be due to the materials being more engaging than a journal article or textbook chapter. This approach has promoted critical thinking and lively discussion of topics of immediate interest in evidence-based medicine among the residents and faculty. Another integration of a modified flipped classroom model is our Tech Talk series. Each fourth-year resident is required to identify one or two interesting podcasts or blogs that are sent to the faculty and residents before the assigned conference time. During conference time, the fourth-year resident then leads a discussion about the disseminated material and highlights any limitations or errors found in the podcast or blog post. Previous topics have included dealing with the difficult consultant, discharge instructions, and palliative care in the emergency department.27-29 We recognize that this approach may not strictly adhere to the fundamentals of the flipped classroom model, but suggest that the information obtained from reviewing the material outside of conference encourages faculty and residents to develop individual opinions and thoughtful discussions of the topics at hand. Not only have these Tech Talk discussions led to more stimulating interactions during conference but also they have generated many resident-driven quality improvement projects. Technological advancement has been the catalyst for exponential growth in the amount of information available to learners. However, the amount of time available for residents to learn is shrinking. The use of the flipped classroom model in residency education may promote more efficient, engaging, and higher-level cognitive learning during didactic sessions, just as it has been shown to do in undergraduate medical education.30 The hope is that the integration of asynchronous methods with traditional classroom didactics would enhance the level of interest, motivation, and retention rate among the learners. Didactics Enhanced by Outside Interaction The most significant potential of social media incorporation into residency education is the ability for real-time, continued feedback and discussion. This will become of particular importance as residencies become inundated with technologically adept millennial learners. Twitter has been described as the “global watercooler [sic] in medicine.”31 Frequently, tweets pose questions or spark discussions. For example, during a panel discussion at our residency about the senior resident job search, we received questions for the panel from residents at other programs through Twitter, which we were then able to pose to the panelists and respond to (Figure 1). Twitter also allows residents to rapidly access experts and educators from around the world. During another recent resident conference, a discussion ensued about whether patients with calf or superficial vein thrombosis should receive anticoagulation. The question was sent by Twitter to Jeffrey Kline (@klinelab), a recognized expert in this area, who immediately responded with his approach (Figure 2). In addition to discussing topics relevant to emergency medicine practice, there is the opportunity to exchange various ways residency programs use their didactic time on Twitter (Figure 3). Volume 64, no. 4 : October 2014
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BARRIERS TO SOCIAL MEDIA USE Generational Gaps and Unfamiliarity One of the most obvious barriers to use may be a lack of familiarity with social media. The Millennial Generation has grown up immersed in technology. As a result, these digital natives are able to effortlessly adopt new technologies.32 Conversely, earlier generations might not as easily do so and as a result might be more reluctant to embrace the use of social media. We believe this lack of familiarity may further prevent individuals from recognizing the power and potential for social media as an educational tool. We think that having more faculty and residents engaged in technology and social media will lead to more meaningful use in residency programs. We have attempted to bridge this knowledge gap by holding workshops for faculty and residents. Specifically, we have attempted to hold a “handson” session covering Twitter and rich site summary feeds, but only some of the attendees participated. We have yet to identify a reliable tactic for engaging individuals resistant to this implementation. Distraction and Disruption There is potential for social media to be distracting and disruptive to other aspects of residency education. For instance, if residents are engrossed in Twitter or other social media platforms during clinical shifts, it could potentially affect patient care or teaching. Other times, there exists the perception of disruption. For example, some speakers at our weekly conference find it disruptive if multiple residents are on their laptops, iPads, and iPhones during their lectures. Many times, these residents are actually quite engaged and are, in fact, tweeting highlights and pearls from the lecture. If speakers are not informed of this beforehand, there exists a potential to offend them. Further, a number of visiting grand rounds speakers have specifically requested that information from their lectures not be tweeted or posted on the Internet for reasons including repetition, liability, and intellectual property. Core Knowledge In social media, some topics are discussed incessantly, whereas others are much less frequently covered. For example, airway management (especially controversial subtopics such as cricoid pressure, induction and paralytic agents, and video versus direct laryngoscopy) are discussed ad nauseam on Twitter and other social media forums, whereas core emergency medicine topics such as basic orthopedics or first-trimester vaginal bleeding are rarely mentioned. Textbooks, however, dedicate roughly an equal number of pages to exciting topics and mundane ones. If an emergency medicine resident uses social media as their sole source of learning, it is possible that many of these important core topics will be overlooked or de-emphasized. As a result, we believe that emergency medicine residents still must use traditional resources such as textbooks to build core knowledge and review the literature for topics that are less often covered by social media. Annals of Emergency Medicine 399
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Figure 1. An example of Twitter use for “inter”-residency discussion.
Several educators have also recognized this problem and have attempted to address it using social media. For example, BoringEM (http://www.boringem.org) was created to address “the unsexy, common aspects of emergency medicine like palliative care, quality improvement, medical education, and urine.”33 EMBasic (http://www.embasic.org) is a podcast and blog about core emergency medicine topics targeted at medical students and interns that is organized by chief complaints.34 Overreliance As the different social media resources become more widely used by emergency residents, a potential concern is the overreliance on free open access meducation as the sole method for critical appraisal of literature. This issue, especially if combined with inadequate literature review training during residency, could lead to emergency medicine residents’ inability to independently interpret primary literature. As such, evidence-based blogs and 400 Annals of Emergency Medicine
podcasts such as the NNT (http://www.thennt.com/), Best Bets (http://www.bestbets.org/), and SMART EM (http://www. smartem.org/) may serve as fundamental resources to a residency’s research and literature review curriculum. Furthermore, it is of utmost importance for the residency leadership to stress the value of reviewing the primary sources and independent learning. Quality Assurance Another notable concern is that open access resources lack peer review before their publication. Although ALiEM is currently testing a peer-review system, a formal quality assurance process does not exist.35 The rebuttal to social media lacking peer review is that the process takes place postpublication through consumers’ comments, but is not necessarily consistent or formal. There is no evidence to suggest that one approach is better than another, but we believe neither is perfect. Recognizing this, our program directors review multiple blogs, podcasts, and videocasts Volume 64, no. 4 : October 2014
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Figure 2. Twitter allows easy access to experts.
to determine the “best” material for the asynchronous portion of our curriculum. This approach involves at most 3 individuals and is not impervious to bias or opinion. Perhaps a better approach would be the identification of best-quality sources to supplement residency curricula through a larger consensus group such as the Council of Emergency Medicine Residency Directors. Quality assurance may also be a problem on Twitter. Although our residency attempts to avoid tweeting inaccurate or highly controversial information, these tweets do not undergo a formal review process and may have unintentionally been inaccurate. Other times, controversial tweets may negatively affect the health system affiliated with a residency program. Although the messages in Twitter are short, tremendous responsibility is allotted to the individuals tweeting from a program’s account. Information Overload Learners may be overwhelmed by information overload with the ever-expanding number of available blogs, podcasts, and videocasts. With so many available resources, learners and educators need to be aware of filtering technologies and Web syndication tools to improve efficiency. An example of a filtering technology is The LIFTL Review, which is a weekly post on Life in the Fast Lane that highlights high-quality posts, podcasts, and tweets in emergency medicine.36 However, this list is determined by a group of individuals. If particular sources are determined to consistently provide reliable substance, Web syndicators such as Feedly or NewsBlur may ease filtering by enabling the aggregation of information from multiple Web sites into a single location. Effectiveness and Residency Review Committee Compliance One of the largest barriers to the incorporation of social media is the lack of research demonstrating an objective measurable Volume 64, no. 4 : October 2014
effect on resident learning. A systematic review of social media use in medical education, published in 2012, found that social media use seemed to correlate with improved knowledge, attitudes about learning, and skills.37 Unfortunately, only 1 of the articles was a randomized controlled trial, highlighting the need for more scientifically rigorous studies examining social media integration and its effects on learners and educators. Another significant barrier is determining how to quantify resident participation and educational effectiveness in a manner that is meaningful and measurable by the Residency Review Committee for Emergency Medicine (RRC). The committee has allowed up to 20% of required didactic curriculum to be individualized, interactive, and asynchronous, provided that resident participation is monitored by the program director. In addition, there must be faculty supervision, evaluation of activities, and measurement of the effectiveness of integration for these components to be acceptable.38 Having residents take quizzes related to material presented through individualized interactive instruction might demonstrate participation and compliance, but not necessarily understanding. Evaluation should measure competency-based metrics to show that the learners actually comprehended and retained the material. With the myriad available platforms and learning preferences, the “input” is effectively different for each individual and source, both in content and understanding. Having a way to measure the “output” in a competence-based manner needs to be the focus. As we continue to move into the next accreditation system as defined by the RRC and Accreditation Council for Graduate Medical Education, ideally the use of open access resources in residency education would demonstrate an improved progression of residents through the different levels of the Emergency Medicine Milestone Project. Annals of Emergency Medicine 401
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Figure 3. A Twitter discussion about the use of debate to teach evidence-based medicine.
Privacy and Professionalism With the use of social media, there exists the potential for lapses in professionalism, privacy violations, and legal liability. The creation of a social media policy outlining both appropriate and inappropriate use is imperative. It is essential to protect patients’ privacy and to uphold professionalism while educators and learners use these tools. In addition, if residencies choose to participate in social media, there needs to be a clearly documented explanation between the program and affiliated institution about what constitutes acceptable and appropriate use. As was the case with our program, the development of a 402 Annals of Emergency Medicine
specific policy may require significant time and discussion among many stakeholders. The American Medical Association, Mayo Clinic, and CORD have published policies on professionalism in the use of social media, and there are a few examples of policies available online.39-41
CONCLUSION In summary, the incorporation of social media into emergency medicine resident education provides opportunities for individualized learning and greater dissemination of Volume 64, no. 4 : October 2014
Scott et al information. There are several available tools and each can be used in different ways. Some platforms are simply a source of information, whereas others allow real-time, active learning with other residents and educators globally. Many resources are freely available for learners and educators who are considering participation.3,42-45 Also, a comprehensive list of blogs, podcasts, and videocasts that may be useful to emergency medicine residency programs can be found on Life in the Fast Lane.46 It is necessary for those participating to be aware of potential barriers and pitfalls in social media use. Of utmost importance is the maintenance of professionalism and patient privacy. With social media gaining in popularity within emergency medicine, we have the unique opportunity to collaborate, create, and share high-quality educational resources from expert educators covering core content. In addition, more controversial or cutting-edge issues can be discussed. With great vigilance and creativity, emergency medicine educators and learners possess the capability to transform medical education in an unprecedented way. The authors acknowledge Michelle Lin, MD, for her insightful suggestions during the initial creation of this article, and David Marcus, MD, Anand Swaminathan, MD, MPH, Jordana Haber, MD, and Jeffrey Kline, MD, for their comments to @UPennEM. Supervising editors: Debra E. Houry, MD, MPH Author affiliations: From the Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). All authors contribute to the Hospital of the University of Pennsylvania’s Emergency Medicine Residency Twitter account @UPennEM and Web site, http://www.PennEM.com.
REFERENCES 1. Cadogan M. EMCC Blog update. LITFL. Available at: http:// lifeinthefastlane.com/emcc-blog-update-2013. Accessed January 8, 2014. 2. Cadogan M, Thoma B, Chan TM, et al. Free open access meducation (FOAM): the rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J. 2014; http://dx.doi.org/10. 1136/emermed-2013-203502. 3. Nickson CP, Cadogan MD. Free open access medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014;26:76-83. 4. Mallin M, Schlein S, Doctor S, et al. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med J Assoc Am Med Coll. 2014;89:598-601. 5. Rezaie S. Residency programs on Twitter. ALIEM. Available at: http:// academiclifeinem.com/em-im-residency-on-twitter. Accessed January 8, 2014. 6. Sandars J, Schroter S. Web 2.0 technologies for undergraduate and postgraduate medical education: an online survey. Postgrad Med J. 2007;83:759-762.
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Social Media and Emergency Medicine Residency Curriculum 7. Berger E. Web 2.0 in emergency medicine: specialty embracing the future of medical communication. Ann Emerg Med. 2012;59:21-23A. 8. Emergency Medicine: Reviews and Perspectives. Available at: http:// www.emrap.org. Accessed March 3, 2014. 9. EMCrit Blog. Available at: http://www.emcrit.org. Accessed March 3, 2014. 10. SMART EM. Available at: http://www.smartem.org. Accessed March 3, 2014. 11. Reiter DA, Lakoff DJ, Trueger NS, et al. Individual interactive instruction: an innovative enhancement to resident education. Ann Emerg Med. 2013;61:110-113. 12. Heiland DH, Petridis AK, Maslehaty H, et al. Efficacy of a new videobased training model in spinal surgery. Surg Neurol Int. 2014;5:1. 13. Mendez A, Seikaly H, Ansari K, et al. High definition video teaching module for learning neck dissection. J Otolaryngol Head Neck Surg. 2014; http://dx.doi.org/10.1186/1916-0216-43-7. 14. Srivastava G, Roddy M, Langsam D, et al. An educational video improves technique in performance of pediatric lumbar punctures. Pediatr Emerg Care. 2012;28:12-16. 15. Bahner DP, Adkins E, Patel N, et al. How we use social media to supplement a novel curriculum in medical education. Med Teach. 2012;34:439-444. 16. Joshi N. Introducing #EMConf Twitter hashtag. ALiEM. Available at: http://academiclifeinem.com/emconf-hashtag. Accessed March 3, 2014. 17. #ACEP13 Healthcare Social Media Analytics. Symplur. Available at: http://www.symplur.com/healthcare-hashtags/ACEP13/analytics/? hashtag¼ACEP13&fdate¼10%2F14%2F2013&shour¼0&smin¼ 0&tdate¼10%2F18%2F2013&thour¼0&tmin¼0&ssec¼00&tsec¼ 00&img¼1. Accessed March 14, 2014. 18. Faust JS. Why we tweet #ACEP13. ACEP Now. Available at: http://www. acepnow.com/article/tweet-acep13. Accessed March 14, 2014. 19. Radecki RP, Rezaie SR, Lin M. Global Emergency Medicine Journal Club: social media responses to the November 2013 Annals of Emergency Medicine Journal Club. Ann Emerg Med. 2014;63:490-494. 20. Lin M. Inaugural global EM journal club—hosted by ALiEM and Annals of EM. ALiEM. Available at: http://academiclifeinem.com/inauguralglobal-em-journal-club-hosted-by-aliem-and-annals-of-em. Accessed March 2, 2014. 21. Chan T. ALiEM–Annals of EM Journal Club: clinical decision rule for subarachnoid hemorrhage. ALiEM. Available at: http:// academiclifeinem.com/journal-club-clinical-decision-rulesubarachnoid-hemorrhage. Accessed March 3, 2014. 22. Perry JJ, Stiell IG, Sivilotti MA, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013;310: 1248-1255. 23. Thoma B. ALiEM–Annals of EM Journal Club: targeted temperature management. ALiEM. Available at: http://academiclifeinem.com/ aliem-annals-em-journal-club-targeted-temperature-management. Accessed May 20, 2014. 24. Nielsen N, et al. Targeted temperature management at 33 C versus 36 C after cardiac arrest. N Engl J Med. 2013;369:2197-2206. 25. Yarris L. Multiple mini interviews (MMI): Annals of EM Resident Perspective article. ALiEM. Available at: http://academiclifeinem.com/ multiple-mini-interviews-annals-em-resident-perspective-article. Accessed May 20, 2014. 26. Phillips AW, Garmel GM. Does the multiple mini-interview address stakeholder needs? an applicant’s perspective. Ann Emerg Med. 2014;64:316-319. 27. Sacchetti A, Herbert M. RANT! Consultants. Available at: https://www. emrap.org/episode/2013/september/rantconsultants. Accessed March 3, 2014. 28. Arora S, Herbert M. The paper chase: the failure of discharge instructions. Available at: https://www.emrap.org/episode/2013/ march/thepaperchase2.
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Social Media and Emergency Medicine Residency Curriculum 29. Shreves A. Critical care palliation. EMCrit Blog. Available at: http:// emcrit.org/podcasts/critical-care-palliation. Accessed March 3, 2014. 30. Prober CG, Heath C. Lecture halls without lectures—a proposal for medical education. N Engl J Med. 2012;366:1657-1659. 31. Lin M. Twitter: the digital watercooler. Emerg Physicians Monthly. Available at http://www.epmonthly.com/subspecialties/technology/ twitter-the-digital-watercooler-. Accessed March 3, 2014. 32. Prensky M. Digital natives, digital immigrants. Horizons. 2001;9:1-6. 33. BoringEM. About BoringEM. Available at: http://boringem.org/about. Accessed March 3, 2014. 34. EM Basic. About and disclaimers. Available at: http://embasic.org/ about. Accessed March 3, 2014. 35. Thoma B, Chan T, Desouza N, et al. Implementing peer review at an emergency medicine blog: bridging the gap between educators and clinical experts. CJEM. 2014;16:21-24. 36. LITFL. LITFL review. Available at: http://lifeinthefastlane.com/blognews/litfl-review. Accessed March 3, 2014. 37. Cheston CC, Flickinger TE, Chisolm MS. Social media use in medical education: a systematic review. Acad Med. 2013;88:893-901. 38. Sadosty AT, Goyal DG, Gene Hern H Jr, et al. Alternatives to the conference status quo: summary recommendations from the 2008 CORD Academic Assembly Conference Alternatives workgroup. Acad Emerg Med. 2009;16(suppl 2):S25-31.
39. American Medical Association Council on Ethical and Judicial Affairs. Professionalism in the use of social media. Available at: http://www.ama-assn.org/resources/doc/code-medical-ethics/ 9124a.pdf. Accessed March 3, 2014. 40. Timimi F. A 12-word social media policy. Available at: http://network. socialmedia.mayoclinic.org/2012/04/05/a-twelve-word-social-mediapolicy. Accessed March 3, 2014. 41. Pillow MT, et al. Social media guidelines and best practices: recommendations from the Council of Residency Directors Social Media Task Force. West J Emerg Med. 2014;15:26-30. 42. Joshi N. Dear program director: get your program on Twitter! ALiEM. Available at: http://academiclifeinem.com/dear-program-director-getyour-program-on-twitter. Accessed March 3, 2014. 43. Lin M. 5 Rules to guide your approach to learning in social media. ALiEM. Available at: http://academiclifeinem.com/5-rulesto-guide-your-approach-to-learning-in-social-media. Accessed March 3, 2013. 44. Kind T, Patel PD, Lie D, et al. Twelve tips for using social media as a medical educator. Med Teach. 2013;36:284-290. 45. Forgie SE, Duff JP, Ross S. Twelve tips for using Twitter as a learning tool in medical education. Med Teach. 2013;35:8-14. 46. LITFL. Available at: http://lifeinthefastlane.com/resources/ emergency-medicine-blogs. Accessed March 3, 2014.
Annals’ Toxicology Resource Center: Acetaminophen Acetaminophen toxicity is now the most common cause of acute hepatic failure. Go to the Resource Center for the best information at www.annemergmed.com.
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Integration of Social Media in Emergency Medicine Residency Curriculum Kevin R. Scott, MD*; Cindy H. Hsu, MD, PhD; Nicholas J. Johnson, MD; Mira Mamtani, MD; Lauren W. Conlon, MD; Francis J. DeRoos, MD *Corresponding Author. E-mail: [email protected], Twitter: @K_ScottMD. 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.05.030
[Ann Emerg Med. 2014;64:396-404.]
INTRODUCTION As education moves away from the age of pen and paper, the digital platform has become a rapidly growing resource for both emergency medicine educators and learners. Social media are any Internet-based applications that enable content sharing and rapid interactions between large populations. The growth and influence of social media technologies have allowed the distribution of ideas far beyond geographic borders.1 During the past decade, an estimated 141 blogs and 42 podcasts related to emergency medicine and critical care have been developed in 24 countries.2 Free open access meducation (FOAM), defined as a community of open access resources for learning in medicine, leverages the powerful sharing and interactive qualities of social media to rapidly disseminate educational materials and expert insights.3 Social media resources are being used frequently by emergency medicine training programs; a recent survey of 226 emergency medicine residents at 12 different residency programs showed that almost 98% use some form of social media for learning for at least 1 hour per week.4 Many emergency medicine residency programs across the United States and Canada have started their own Twitter accounts (Table), largely through the work of the group at Academic Life in Emergency Medicine (ALiEM).5 Despite the strong tendency to use social media for learning, there remains a lack of understanding or science of how to implement it effectively.6 Our primary goal is to describe the different social media modalities and how our program and others have created a presence in these platforms. We will also offer specific examples of how these modalities can be integrated asynchronously or in conjunction with didactic sessions. Last, we will highlight the potential struggles and barriers that may be associated with the implementation and integration of social media in residency education. We hope that this article will spark further discussion on social media use and inspire future studies to examine the effectiveness of its integration in emergency medicine residency curricula.
SOCIAL MEDIA MODALITIES Blogs Blogs are Web sites where individuals or groups can post material. They serve as useful ways for educators to compile and 396 Annals of Emergency Medicine
disseminate information. Popular blogs in emergency medicine education include ALiEM (http://www.academiclifeinem.com) and Life in the Fast Lane (http://www.lifeinthefastlane.com). Some emergency medicine training programs have created their own blogs that incorporate posts from faculty, fellows, and residents. SUNY Downstate’s The Original Kings of County (http://www.blog.clinicalmonster.com) includes frequent educational posts spanning the realms of trauma, toxicology, and critical care. In addition, they provide brief synopses of their program’s morning reports and journal clubs. The University of Maryland posts daily educational pearls (http://www.umem.org/ educational_pearls) that are available to anyone. In addition, the critical care fellows at the University of Maryland have created a blog dedicated to sharing content from their didactic curriculum to highlight controversial and cutting-edge topics in critical care (http://www.marylandccproject.org). Finally, the discussion of practice variability is one of the main themes behind a blog from New York University–Bellevue Hospital known as EM Lyceum (http://emlyceum.com). Blogs are useful ways for residency programs to rapidly and consistently disseminate educational content to their residents, and they also allow interaction and discussion among residency programs. Although blogs vary in their format, quality, and content, many of them enable residents to rapidly access concise, current, and referenced synopses of clinical and educational material that can be used for on-shift (“on-the-fly”) learning and can point them to relevant primary literature. Because emergency medicine is both science and art, a key component of residency training is learning from the experiences of others. Often, there is a dearth of experiential commentary in traditional learning resources such as journal articles and textbooks, but blogs allow this important information to be conveyed. Podcasts A podcast is composed of digitally recorded material that can be downloaded or streamed by users. They are typically audio files, but may be recorded in other formats as well. Podcasts have been used extensively by emergency physicians as ways to disseminate traditional lecture material to a multitude of learners. EMCrit (http://www.emcrit.org) is a great example of how one educator uses podcasts to share his knowledge with many more Volume 64, no. 4 : October 2014
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Table. Emergency medicine residency Twitter accounts in the United States and Canada. Program Baystate Health Beth Israel Medical Center Beth Israel Deaconess Medical Center Boston Medical Center Brooklyn Hospital Brown University Carolinas Medical Center Conemaugh Memorial Medical Center Dartmouth-Hitchcock Drexel University Duke University East Carolina University Emory University Genesys Regional Medical Center Grandview Medical Center Harbor-UCLA Medical Center Highland General Hospital Indiana University Jacobi/Montefiore Kaiser Permanente San Diego Kelowna General Hospital London Health Sciences Centre Long Island Jewish Medical Center Lincoln Medical and Mental Health Center Maimonides Medical Center Maricopa Medical Center Mayo Clinic McGill University McLaren Macomb Mount Sinai NYU/Bellevue
Twitter Handle
Program
Twitter Handle
@BaystateEM @BethIsraelEMED @BIDMCEM @BMCEmergency @bkhospital @BrownEMRes @CMCEM @ConemaughEMres @dartmouthem @DrexelEmergency @dukeemergency @ECU_EM @EmoryEM @GenesysEM @GrandviewEM @HarborUCLAEM @HGHED @IUEmergencyMed @Jacobi_EM @Sdmeded @FRCPMKelowna @emergencylondon @LIJ_EM @LincolnEM @Maimonides_EM @MaricopaEM @MayoClinicEM @mcgill_emerg @McLarenMacEM @SinaiEM @NYUEMChiefs
Olive View–UCLA Medical Center Oregon Health & Sciences University Parkland Memorial Hospital Queen’s University Regions Hospital Staten Island University Hospital Stanford/Kaiser St. Luke’s–Roosevelt St. Joseph’s Healthcare System SUNY Downstate/Kings County Hospital Center Temple University Texas A&M–Christus Spohn University of Alabama University of Arizona University of Arkansas University of California–Davis University of California–Irvine University of Chicago University of Cincinnati University of Illinois–Peoria University of Kentucky University of Maryland University of Missouri University of Nevada University of Ottawa University of Pennsylvania University of Texas at Houston Washington University WellSpan York Hospital Wright State University Yale University
@UCLAEMRes @OHSUEmergency @DallasEMed @Qemerg @regionsem @statenislandem @StanfordEMRes @SLREM @StJoesEM @kingsofcounty @TempleEM @CCEMRP @uabem @UAEMresidency @UAMSED @UCDEmergMed @UCIrvineEM @UChicagoEM @UCMorning Report @UICOMPEM @WildcatEMres @UMEmergencyMed @MizzouEM @LasVegasEM @emergmedottawa @UPennEM @UTEmergencyMed @WashUEM @WellSpanYHEMdoc @WrightStEM @yaleem2
learners than are typically reached with traditional lectures.7 EMCrit and other podcasts such as SMART EM (http://www. smartem.org) and EM Basic (http://www.embasic.org) are free, open-access resources that distribute lectures, interviews, and discussions about emergency medicine and critical care. Another podcast, although not open access, is EM:RAP (http://www. emrap.org), which is most popular among emergency medicine residents because it is provided as a free benefit with Emergency Medicine Resident Association membership.4 Our program has incorporated podcasts as adjuncts to our modular curriculum. Each month, residents are provided with a list of podcasts that are relevant to the core topics being covered during that period. The podcasts are selected by our residency leadership according to their quality and relevance to the modular block from multiple aforementioned resources.8-10 Residents are required to listen to the podcasts and answer online questions about the materials reviewed. This integration has allowed a portion of required learning to be completed when it is most convenient for the residents, as well as increased interactive discussions during weekly conference time. The residency program at Mount Sinai in New York has described a similar approach. Their residents are provided with optional instructive resources and asked to answer questions about the content.11 Similar to our program, such integration has Volume 64, no. 4 : October 2014
also replaced 1 hour of Mount Sinai’s formal conference time each week, allowing the residents to learn on their own time. Videocasts Videocasts are similar to podcasts, but as the name suggests, episodes are in a video format. Several studies have shown improved procedural techniques when residents are taught through videos and may be one of the most effective ways to integrate social media into emergency medicine resident education.12-14 They are especially useful for the demonstration of rarely performed procedures and the dissemination of visual content such as images and ECGs. Furthermore, videocasts can rapidly incorporate the expertise of educators from other hospitals into a residency’s curriculum without incurring substantial travel expenses and time. Examples of high-quality videocasts include Hennepin County Medical Center’s instructional videos on a variety of emergency medicine–related topics, including trauma, ECGs, and procedures (http://www.hqmeded.com). In addition, the University of Maryland also offers a series of instructional procedure videos, as well as videos for oral board preparation (http://www.umem.org/page/education/residency/video_ training). Finally, the Patwari Video Academy (http://www. academiclifeinem.com/category/clinical/patwari-videos) teaches Annals of Emergency Medicine 397
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Social Media and Emergency Medicine Residency Curriculum various core emergency medicine topics by using a whiteboard animation application combined with recorded audio. Twitter The use of the microblog Twitter has become a popular route for educators to share concise pearls and reference links to useful resources. Blogs, podcasts, and videocasts are powerful disseminators of information but may require significant time for the learners to participate. We believe that learners with demanding schedules crave educational pearls and relevant references that are pertinent to a particular topic. Bahner et al15 described the use of “push” technology to distribute educational pearls about point-of-care ultrasonography to the emergency medicine residents at Ohio State University through the Twitter handle @EDUltrasound. Push technology can be described as an Internet-based communication in which the platform provides information as it is made available rather than the user needing to “pull” or refresh information. A majority of followers of @EDUltrasound found the tweets to include useful information. In addition to individuals sharing their own educational snippets, emergency medicine residencies have embraced Twitter as a means to share pearls from weekly didactic sessions through the use of the #EMConf hashtag.16 “Tweeters” share and spread information from a learning session to other consumers. For example, our program has a Twitter account that is used primarily to share highlights from didactic sessions and simulations (http://www.twitter.com/UPennEM). The chief residents are responsible for selecting and then tweeting pearls from lectures, which has allowed our own residents who may be on off-service rotations to follow conferences asynchronously. In addition, individuals who worked the previous evening and are not present for all of conference time can review highlights from a given day’s didactics. Consumers of these tweets include not only our own residents but also hundreds more who have chosen to follow the account. Before the launch of the #EMConf hashtag, Twitter was used to disseminate content from regional and national conferences. Examples of these conferences included the 2013 regional Delaware Valley American Academy of Emergency Medicine conference (#DVAAEM13) in Philadelphia, 2013 Society for Academic Emergency Medicine annual meeting (#SAEM13) in Atlanta, and 2013 American College of Emergency Physicians (ACEP) Scientific Assembly (#ACEP13) in Seattle. Conference live tweeting has continued to increase in popularity, with an increase to 1,332 individual tweeters at the 2013 American College of Emergency Physicians Scientific Assembly from only 294 at the 2012 meeting.17 In 2013, the inaugural Social Media and Critical Care Conference took place in Australia. There were more than 16,000 total tweets that incorporated the hashtag #SMACC13, but of more significance was the innovative integration of social media into the conference.18 Sessions included Google Hangouts with speakers, live-streamed sessions, and recorded sessions with the purpose of eventually making them available through YouTube. Conference speakers could 398 Annals of Emergency Medicine
easily disseminate lecture pearls, and more important, learners who could not attend the conferences were able to follow the didactic sessions. Google Hangouts Google Hangouts is a free utility that allows multiuser video conferencing and messaging, and has potential to be a powerful tool for interactive education. This platform allows real-time discussion and learning without participants being at the same location. Recently, it has been used in combination with other social media modalities by ALiEM and Annals of Emergency Medicine to create a venue for a global journal club using the Twitter hashtags #ALiEMJC and #ALiEMRP. The ALiEM Web site first served as a forum for the discussion of several questions about a journal article during multiple days.19,20 Using Google Hangouts, learners were then able to directly ask the authors questions and discuss their interpretations of the article’s findings in real time. For example, the authors answered curated questions on the clinical decision rules for subarachnoid hemorrhage, post–cardiac arrest targeted temperature management, and the nuances of multiple mini interviews during residency recruitment.21-26 These global journal clubs and the discussion of the multiple mini interviews article demonstrated that the combination of different social media modalities creates innumerable opportunities for real-time discussion. We are unaware of any programs that have used this modality during their didactic sessions, but believe this may be another potential powerful tool for residency education.
FURTHER INTEGRATION Flipped Classroom With so many open access resources, learners can easily individualize their education according to their needs and interests. Integration of asynchronous, individualized learning with the classroom is the basis of what is known as the “flipped classroom.” The idea is that fundamental knowledge is gained by the individual learner on his or her own time, and the classroom becomes the setting to apply that knowledge. This educational model offers a unique venue for learners to discuss their “take aways” and interpretation of a podcast or blog. Our residency has integrated modified versions of the flipped classroom model, using social media in a few specific ways with a debate format and a discussion-based Tech Talk series. Through the debate format, senior residents and faculty participate in an evidence-based discussion about the clinical management of an acute disease process; an example would be rhythm versus rate control for atrial fibrillation. Before the debate, residents and faculty are sent several podcasts and articles chosen by the residency leadership that are related to the evidence available about a controversial topic. Additional literature review is conducted by the senior resident leading the discussion. A moderated debate then occurs during scheduled conference time involving faculty and residents. We believe that providing blog entries or podcasts for review before conference results in more Volume 64, no. 4 : October 2014
Scott et al participation during the asynchronous component and may be due to the materials being more engaging than a journal article or textbook chapter. This approach has promoted critical thinking and lively discussion of topics of immediate interest in evidence-based medicine among the residents and faculty. Another integration of a modified flipped classroom model is our Tech Talk series. Each fourth-year resident is required to identify one or two interesting podcasts or blogs that are sent to the faculty and residents before the assigned conference time. During conference time, the fourth-year resident then leads a discussion about the disseminated material and highlights any limitations or errors found in the podcast or blog post. Previous topics have included dealing with the difficult consultant, discharge instructions, and palliative care in the emergency department.27-29 We recognize that this approach may not strictly adhere to the fundamentals of the flipped classroom model, but suggest that the information obtained from reviewing the material outside of conference encourages faculty and residents to develop individual opinions and thoughtful discussions of the topics at hand. Not only have these Tech Talk discussions led to more stimulating interactions during conference but also they have generated many resident-driven quality improvement projects. Technological advancement has been the catalyst for exponential growth in the amount of information available to learners. However, the amount of time available for residents to learn is shrinking. The use of the flipped classroom model in residency education may promote more efficient, engaging, and higher-level cognitive learning during didactic sessions, just as it has been shown to do in undergraduate medical education.30 The hope is that the integration of asynchronous methods with traditional classroom didactics would enhance the level of interest, motivation, and retention rate among the learners. Didactics Enhanced by Outside Interaction The most significant potential of social media incorporation into residency education is the ability for real-time, continued feedback and discussion. This will become of particular importance as residencies become inundated with technologically adept millennial learners. Twitter has been described as the “global watercooler [sic] in medicine.”31 Frequently, tweets pose questions or spark discussions. For example, during a panel discussion at our residency about the senior resident job search, we received questions for the panel from residents at other programs through Twitter, which we were then able to pose to the panelists and respond to (Figure 1). Twitter also allows residents to rapidly access experts and educators from around the world. During another recent resident conference, a discussion ensued about whether patients with calf or superficial vein thrombosis should receive anticoagulation. The question was sent by Twitter to Jeffrey Kline (@klinelab), a recognized expert in this area, who immediately responded with his approach (Figure 2). In addition to discussing topics relevant to emergency medicine practice, there is the opportunity to exchange various ways residency programs use their didactic time on Twitter (Figure 3). Volume 64, no. 4 : October 2014
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BARRIERS TO SOCIAL MEDIA USE Generational Gaps and Unfamiliarity One of the most obvious barriers to use may be a lack of familiarity with social media. The Millennial Generation has grown up immersed in technology. As a result, these digital natives are able to effortlessly adopt new technologies.32 Conversely, earlier generations might not as easily do so and as a result might be more reluctant to embrace the use of social media. We believe this lack of familiarity may further prevent individuals from recognizing the power and potential for social media as an educational tool. We think that having more faculty and residents engaged in technology and social media will lead to more meaningful use in residency programs. We have attempted to bridge this knowledge gap by holding workshops for faculty and residents. Specifically, we have attempted to hold a “handson” session covering Twitter and rich site summary feeds, but only some of the attendees participated. We have yet to identify a reliable tactic for engaging individuals resistant to this implementation. Distraction and Disruption There is potential for social media to be distracting and disruptive to other aspects of residency education. For instance, if residents are engrossed in Twitter or other social media platforms during clinical shifts, it could potentially affect patient care or teaching. Other times, there exists the perception of disruption. For example, some speakers at our weekly conference find it disruptive if multiple residents are on their laptops, iPads, and iPhones during their lectures. Many times, these residents are actually quite engaged and are, in fact, tweeting highlights and pearls from the lecture. If speakers are not informed of this beforehand, there exists a potential to offend them. Further, a number of visiting grand rounds speakers have specifically requested that information from their lectures not be tweeted or posted on the Internet for reasons including repetition, liability, and intellectual property. Core Knowledge In social media, some topics are discussed incessantly, whereas others are much less frequently covered. For example, airway management (especially controversial subtopics such as cricoid pressure, induction and paralytic agents, and video versus direct laryngoscopy) are discussed ad nauseam on Twitter and other social media forums, whereas core emergency medicine topics such as basic orthopedics or first-trimester vaginal bleeding are rarely mentioned. Textbooks, however, dedicate roughly an equal number of pages to exciting topics and mundane ones. If an emergency medicine resident uses social media as their sole source of learning, it is possible that many of these important core topics will be overlooked or de-emphasized. As a result, we believe that emergency medicine residents still must use traditional resources such as textbooks to build core knowledge and review the literature for topics that are less often covered by social media. Annals of Emergency Medicine 399
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Figure 1. An example of Twitter use for “inter”-residency discussion.
Several educators have also recognized this problem and have attempted to address it using social media. For example, BoringEM (http://www.boringem.org) was created to address “the unsexy, common aspects of emergency medicine like palliative care, quality improvement, medical education, and urine.”33 EMBasic (http://www.embasic.org) is a podcast and blog about core emergency medicine topics targeted at medical students and interns that is organized by chief complaints.34 Overreliance As the different social media resources become more widely used by emergency residents, a potential concern is the overreliance on free open access meducation as the sole method for critical appraisal of literature. This issue, especially if combined with inadequate literature review training during residency, could lead to emergency medicine residents’ inability to independently interpret primary literature. As such, evidence-based blogs and 400 Annals of Emergency Medicine
podcasts such as the NNT (http://www.thennt.com/), Best Bets (http://www.bestbets.org/), and SMART EM (http://www. smartem.org/) may serve as fundamental resources to a residency’s research and literature review curriculum. Furthermore, it is of utmost importance for the residency leadership to stress the value of reviewing the primary sources and independent learning. Quality Assurance Another notable concern is that open access resources lack peer review before their publication. Although ALiEM is currently testing a peer-review system, a formal quality assurance process does not exist.35 The rebuttal to social media lacking peer review is that the process takes place postpublication through consumers’ comments, but is not necessarily consistent or formal. There is no evidence to suggest that one approach is better than another, but we believe neither is perfect. Recognizing this, our program directors review multiple blogs, podcasts, and videocasts Volume 64, no. 4 : October 2014
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Figure 2. Twitter allows easy access to experts.
to determine the “best” material for the asynchronous portion of our curriculum. This approach involves at most 3 individuals and is not impervious to bias or opinion. Perhaps a better approach would be the identification of best-quality sources to supplement residency curricula through a larger consensus group such as the Council of Emergency Medicine Residency Directors. Quality assurance may also be a problem on Twitter. Although our residency attempts to avoid tweeting inaccurate or highly controversial information, these tweets do not undergo a formal review process and may have unintentionally been inaccurate. Other times, controversial tweets may negatively affect the health system affiliated with a residency program. Although the messages in Twitter are short, tremendous responsibility is allotted to the individuals tweeting from a program’s account. Information Overload Learners may be overwhelmed by information overload with the ever-expanding number of available blogs, podcasts, and videocasts. With so many available resources, learners and educators need to be aware of filtering technologies and Web syndication tools to improve efficiency. An example of a filtering technology is The LIFTL Review, which is a weekly post on Life in the Fast Lane that highlights high-quality posts, podcasts, and tweets in emergency medicine.36 However, this list is determined by a group of individuals. If particular sources are determined to consistently provide reliable substance, Web syndicators such as Feedly or NewsBlur may ease filtering by enabling the aggregation of information from multiple Web sites into a single location. Effectiveness and Residency Review Committee Compliance One of the largest barriers to the incorporation of social media is the lack of research demonstrating an objective measurable Volume 64, no. 4 : October 2014
effect on resident learning. A systematic review of social media use in medical education, published in 2012, found that social media use seemed to correlate with improved knowledge, attitudes about learning, and skills.37 Unfortunately, only 1 of the articles was a randomized controlled trial, highlighting the need for more scientifically rigorous studies examining social media integration and its effects on learners and educators. Another significant barrier is determining how to quantify resident participation and educational effectiveness in a manner that is meaningful and measurable by the Residency Review Committee for Emergency Medicine (RRC). The committee has allowed up to 20% of required didactic curriculum to be individualized, interactive, and asynchronous, provided that resident participation is monitored by the program director. In addition, there must be faculty supervision, evaluation of activities, and measurement of the effectiveness of integration for these components to be acceptable.38 Having residents take quizzes related to material presented through individualized interactive instruction might demonstrate participation and compliance, but not necessarily understanding. Evaluation should measure competency-based metrics to show that the learners actually comprehended and retained the material. With the myriad available platforms and learning preferences, the “input” is effectively different for each individual and source, both in content and understanding. Having a way to measure the “output” in a competence-based manner needs to be the focus. As we continue to move into the next accreditation system as defined by the RRC and Accreditation Council for Graduate Medical Education, ideally the use of open access resources in residency education would demonstrate an improved progression of residents through the different levels of the Emergency Medicine Milestone Project. Annals of Emergency Medicine 401
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Figure 3. A Twitter discussion about the use of debate to teach evidence-based medicine.
Privacy and Professionalism With the use of social media, there exists the potential for lapses in professionalism, privacy violations, and legal liability. The creation of a social media policy outlining both appropriate and inappropriate use is imperative. It is essential to protect patients’ privacy and to uphold professionalism while educators and learners use these tools. In addition, if residencies choose to participate in social media, there needs to be a clearly documented explanation between the program and affiliated institution about what constitutes acceptable and appropriate use. As was the case with our program, the development of a 402 Annals of Emergency Medicine
specific policy may require significant time and discussion among many stakeholders. The American Medical Association, Mayo Clinic, and CORD have published policies on professionalism in the use of social media, and there are a few examples of policies available online.39-41
CONCLUSION In summary, the incorporation of social media into emergency medicine resident education provides opportunities for individualized learning and greater dissemination of Volume 64, no. 4 : October 2014
Scott et al information. There are several available tools and each can be used in different ways. Some platforms are simply a source of information, whereas others allow real-time, active learning with other residents and educators globally. Many resources are freely available for learners and educators who are considering participation.3,42-45 Also, a comprehensive list of blogs, podcasts, and videocasts that may be useful to emergency medicine residency programs can be found on Life in the Fast Lane.46 It is necessary for those participating to be aware of potential barriers and pitfalls in social media use. Of utmost importance is the maintenance of professionalism and patient privacy. With social media gaining in popularity within emergency medicine, we have the unique opportunity to collaborate, create, and share high-quality educational resources from expert educators covering core content. In addition, more controversial or cutting-edge issues can be discussed. With great vigilance and creativity, emergency medicine educators and learners possess the capability to transform medical education in an unprecedented way. The authors acknowledge Michelle Lin, MD, for her insightful suggestions during the initial creation of this article, and David Marcus, MD, Anand Swaminathan, MD, MPH, Jordana Haber, MD, and Jeffrey Kline, MD, for their comments to @UPennEM. Supervising editors: Debra E. Houry, MD, MPH Author affiliations: From the Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). All authors contribute to the Hospital of the University of Pennsylvania’s Emergency Medicine Residency Twitter account @UPennEM and Web site, http://www.PennEM.com.
REFERENCES 1. Cadogan M. EMCC Blog update. LITFL. Available at: http:// lifeinthefastlane.com/emcc-blog-update-2013. Accessed January 8, 2014. 2. Cadogan M, Thoma B, Chan TM, et al. Free open access meducation (FOAM): the rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J. 2014; http://dx.doi.org/10. 1136/emermed-2013-203502. 3. Nickson CP, Cadogan MD. Free open access medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014;26:76-83. 4. Mallin M, Schlein S, Doctor S, et al. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med J Assoc Am Med Coll. 2014;89:598-601. 5. Rezaie S. Residency programs on Twitter. ALIEM. Available at: http:// academiclifeinem.com/em-im-residency-on-twitter. Accessed January 8, 2014. 6. Sandars J, Schroter S. Web 2.0 technologies for undergraduate and postgraduate medical education: an online survey. Postgrad Med J. 2007;83:759-762.
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Social Media and Emergency Medicine Residency Curriculum 7. Berger E. Web 2.0 in emergency medicine: specialty embracing the future of medical communication. Ann Emerg Med. 2012;59:21-23A. 8. Emergency Medicine: Reviews and Perspectives. Available at: http:// www.emrap.org. Accessed March 3, 2014. 9. EMCrit Blog. Available at: http://www.emcrit.org. Accessed March 3, 2014. 10. SMART EM. Available at: http://www.smartem.org. Accessed March 3, 2014. 11. Reiter DA, Lakoff DJ, Trueger NS, et al. Individual interactive instruction: an innovative enhancement to resident education. Ann Emerg Med. 2013;61:110-113. 12. Heiland DH, Petridis AK, Maslehaty H, et al. Efficacy of a new videobased training model in spinal surgery. Surg Neurol Int. 2014;5:1. 13. Mendez A, Seikaly H, Ansari K, et al. High definition video teaching module for learning neck dissection. J Otolaryngol Head Neck Surg. 2014; http://dx.doi.org/10.1186/1916-0216-43-7. 14. Srivastava G, Roddy M, Langsam D, et al. An educational video improves technique in performance of pediatric lumbar punctures. Pediatr Emerg Care. 2012;28:12-16. 15. Bahner DP, Adkins E, Patel N, et al. How we use social media to supplement a novel curriculum in medical education. Med Teach. 2012;34:439-444. 16. Joshi N. Introducing #EMConf Twitter hashtag. ALiEM. Available at: http://academiclifeinem.com/emconf-hashtag. Accessed March 3, 2014. 17. #ACEP13 Healthcare Social Media Analytics. Symplur. Available at: http://www.symplur.com/healthcare-hashtags/ACEP13/analytics/? hashtag¼ACEP13&fdate¼10%2F14%2F2013&shour¼0&smin¼ 0&tdate¼10%2F18%2F2013&thour¼0&tmin¼0&ssec¼00&tsec¼ 00&img¼1. Accessed March 14, 2014. 18. Faust JS. Why we tweet #ACEP13. ACEP Now. Available at: http://www. acepnow.com/article/tweet-acep13. Accessed March 14, 2014. 19. Radecki RP, Rezaie SR, Lin M. Global Emergency Medicine Journal Club: social media responses to the November 2013 Annals of Emergency Medicine Journal Club. Ann Emerg Med. 2014;63:490-494. 20. Lin M. Inaugural global EM journal club—hosted by ALiEM and Annals of EM. ALiEM. Available at: http://academiclifeinem.com/inauguralglobal-em-journal-club-hosted-by-aliem-and-annals-of-em. Accessed March 2, 2014. 21. Chan T. ALiEM–Annals of EM Journal Club: clinical decision rule for subarachnoid hemorrhage. ALiEM. Available at: http:// academiclifeinem.com/journal-club-clinical-decision-rulesubarachnoid-hemorrhage. Accessed March 3, 2014. 22. Perry JJ, Stiell IG, Sivilotti MA, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013;310: 1248-1255. 23. Thoma B. ALiEM–Annals of EM Journal Club: targeted temperature management. ALiEM. Available at: http://academiclifeinem.com/ aliem-annals-em-journal-club-targeted-temperature-management. Accessed May 20, 2014. 24. Nielsen N, et al. Targeted temperature management at 33 C versus 36 C after cardiac arrest. N Engl J Med. 2013;369:2197-2206. 25. Yarris L. Multiple mini interviews (MMI): Annals of EM Resident Perspective article. ALiEM. Available at: http://academiclifeinem.com/ multiple-mini-interviews-annals-em-resident-perspective-article. Accessed May 20, 2014. 26. Phillips AW, Garmel GM. Does the multiple mini-interview address stakeholder needs? an applicant’s perspective. Ann Emerg Med. 2014;64:316-319. 27. Sacchetti A, Herbert M. RANT! Consultants. Available at: https://www. emrap.org/episode/2013/september/rantconsultants. Accessed March 3, 2014. 28. Arora S, Herbert M. The paper chase: the failure of discharge instructions. Available at: https://www.emrap.org/episode/2013/ march/thepaperchase2.
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Annals’ Toxicology Resource Center: Acetaminophen Acetaminophen toxicity is now the most common cause of acute hepatic failure. Go to the Resource Center for the best information at www.annemergmed.com.
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