MEdIC Series: The Case of the Absentee Audience – Expert & Community Commentary

MEdIC SeriesThis month for the ALiEM MEdIC Series, we presented the Case of the Absentee Audience, which depicts a lecturer who experienced a particularly challenging problem with her audience – absenteeism. Her audience was both physically and mentally absent, and as such, the cause of much frustration. In keeping with our mandate with the MEdIC Series, we launched this case last week and waited for the crowd to speak up and help us solve the case. (And boy, did they EVER!) We also asked two esteemed colleagues to prepare some expert consultations on the case. Continue reading to see what everyone had to say.

This month Eve Purdy (@purdy_eve), Sarah Luckett-Gatopoulos (@SLuckettG), and I (@TChanMD) led a discussion that explored a very complex scenario. With the help of Brent Thoma, we had also previously solicited with insights from 2 experts. This follow-up post includes:

  • The responses of our medical education experts, Drs. James Ahn (@ahnjam) and Stella Yiu (@stella_yiu)
  • A summary of insights from the ALiEM community derived from the Twitter  and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities

Expert response 1: Web 2.0: How I Learned to Love the Millennial Learner

James Ahn, MD (@ahnjam)
Associate Program Director and Medical Education Fellowship Director at the University of Chicago

Dr. Xiu’s audience response is not uncommon when lectures are used as the primary instructional strategy. Unless faculty members are gifted storytellers, lecturing as an instructional strategy for core content will be met with the same palpable disinterest expressed in this case.

The Problem(s)

Time Constraints
Although this didactic session was mandatory, audience attendance was not reflective of that. The target audience had multiple competing time demands that detracted from  their attendance. Also, conference attendance may be influenced by cultural issues in the residency program. We must consider that learners may be “voting with their feet” if they are not interesting in attending lectures.

Learner Interest
Not only did a half-full auditorium demonstrate a lack of interest, the behavior demonstrated by the present learners showed a dearth of enthusiasm. Akin to a visual analog pain scale, learners interest can be judged from texting or napping (sad face) to eager nods and questions (happy face).

Unfortunately, based on audience response, Dr. Xiu’s didactic session fails to capture the interest of her target audience.

The Solutions

Relieving Time Constraints
Unless Dr. Xiu is part of the residency program leadership, she may have a difficult time advocating for increasing protected time for residents or changing the culture to create a sacrosanct time for conference. However, Dr. Xiu can appeal to the program leadership that if conference attendance is a persistent problem, then the residents will be in danger of failing to meet ACGME requirement that residents must participate in 70% of all planned didactic experiences (1). The program leadership may be to motivated to change the culture of the residency or even implement different staffing models to allow residents the time to attend didactics (2,3).

Increasing Learner Interest
The millennials, or Generation Y, are a generational group defined by Howe and Strauss as people who have turned 18 in the year 2000 and entered college or entered the adult workforce (4). As the median age of medical school matriculants in 2011 is 23-24, the current generation of medical trainees are primarily millennials (5). This generation has been exposed to technology from a very young age and considers it an essential enabling device for their education (6). Teaching suggestions for the millennial generation often center around appropriate usage of technology to engage this group of learners (7). Further, learning activities that involve interactivity, group learning, and multiple media modalities have a higher chance of successfully engaging them (6,7). In fact, millennials have “little desire to read long texts” and delivery of instruction is preferable in short media segments (8,9). Dr. Xiu’s lecture is a case study in alienating the millennial learner.

Strategies for Engaging the Millennial
The “flipped classroom” design as described Salman Khan, espouses an educational philosophy that speaks to the Millennial generation (10). This teaching ideology requires student to access online videos to learn concepts prior to the classroom. The classroom can then serve as a vessel for robust discussion between the expert and learners. “Flipping the classroom” encourages interactivity in the classroom while replacing long texts with short media segments for the Millennial learner. This design has been shown to be effective with our current crop of learners and has increasingly been a focal rallying point for educational change (11-14). Dr. Xiu may choose to “flip the classroom” in any number of ways. For example, she may choose to split the classroom in to multiple groups and assign video vignettes to each group for discussion during conference time. Also, Dr. Xiu can consider offering the same video to all the learners with embedded discussion points for the classroom.

The social web, or Web 2.0, also offers an educational tool that can serve the millennials preferred style of learning. It is the newest manifestation of the web that supports and encourages social interactivity and collaboration. Types of web 2.0 applications frequently used in education include blogs, wikis, podcasts, social media(15). Over 70% of millennials use social networking sites and approximately one-fifth read blogs and wikis (16). Because web 2.0 holds a natural application as an educational tool for the millennials, there is no reason that this should not be mined by educators. The explosion of Free Open Access Meducation (FOAM) suggests that our learners have already cast their vote(17). Web 2.0 can be used in a number of creative ways.

In this case, Dr. Xiu could use social media resources as her vehicle for “flipping the classroom” and delivering educational content beforehand. The challenge comes, then, to fill the interactive time with learners – a skill that Dr. Xiu will need to develop since it is not well taught presently. For instance, she might encourage the use of Web 2.0 to search for evidence-based medicine to support or debunk therapeutic hypothermia during her classroom discussion in a modified problem-based learning or “Big Questions” session – acting more as a guide or one of Sugata Mitra’s “Grannies” who encourage students to find the answers themselves. Finally, she may consider using Twitter as a multiplier and engage the entire FOAM community by encouraging her learners to live-Tweet during conference (18).

Albert Einstein said: “Insanity is doing the same thing over and over again and expecting different results.” Lecturing to this current crop of learners will prove to be unsuccessful. Faculty members must be agile in their educational strategies to meet and engage learners along their interests and expectations. Currently, these interests lie in technology available in short media segments, group work and interactivity. The challenge moving forward for faculty is to incorporate these elements in each teaching session.

  1. ACGME emergency medicine requirements. Accessed March 14, 2014.
  2. Roey S. Medical education and ACGME duty hour requirements: assessing the effect of a day float system on educational activities. Teach Learn Med. 2006;18(1):28-34.
  3. Theobald CN, et al. The effect of reducing maximum shift lengths to 16 hours on internal medicine interns’ educational opportunities. Acad Med. 2013;88(4):512-8.
  4. Howe N and Strauss W. Millennials rising: the next great generation. New York: Vintage Books, 2000
  5. Applicants and matriculants data. Association of American medical colleges 2011. Accessed March 14, 2013.
  6. Oblinger D, Oblinger J. Educating the net generation [PDF]. 2004. Accessed March 15, 2013
  7. Roberts, DH, et al. Twelve tips for facilitating millennials’ learning. Med Teach. 2012;34:274-8.
  8. McCurry, MK, et al. Teaching undergraduate nursing research: a comparison of traditional and innovative approaches for success with millennial learners. J Nurs Educ. 2010;49(5):276-9.
  9. Twenge JM. Generational changes and their impact in the classroom: teaching generation me. Med Educ. 2009;43:398-405.
  10. Let’s use video to reinvent education. [TED video] Accessed March 19th, 2014.
  11. McLaughlin JE, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. 2014;89(2):236-43.
  12. Tune JD, et al. Flipped classroom model improves graduate student performance in cardiovascular, respiratory, and renal physiology. Adv Physiol Educ. 2013;37(4):316-20.
  13. Kurup V, et al. The changing landscape of anesthesia education: is Flipped Classroom the answer? Curr Opin Anaesthesiol. 2013;26(6):726-31
  14. Prober CG, et al. Medical education reimagined: a call to action. Acad Med. 2013;88(10):1407-10.
  15. Boulos, MN, et al. The emerging web 2.0 social software: an enabling suite of sociable technologies in health and health care education. Health Info Libr J. 2007;24:2-23.
  16. Sandars J, et al. Web 2.0 and social software: the medical student way of e-learning. Med Teach. 2010;30:308-12.
  17. Cadogan M, et al. Free Open Access Meducation (FOAM): the rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J. 2014 [Epub ahead of print]
  18.   Neil A, et al. The impact of social media on a major international emergency medicine conference. Emerg Med J. 2013 Feb 19. [Epub ahead of print]

Expert response 2: Listening and Engaging: Trade secrets for combating the absentee audience

Stella Yiu (@stella_yiu)
Assistant Professor, University of Ottawa. She is the brains behind the Flipped EM Classroom.

For Dr. Xiu to engage the audience, I would suggest that she tailor concrete objectives for the audience and build in active elements to increase learning.

1.  Tailor content to the audience
As a first step, Dr. Xiu should find out what the audience needs from her, the content expert.  She could do a needs assessment about what the learners know about the topic using a free online survey tool like Survey Monkey to discover any beliefs and controversies.

Once she has decided on her content, she should break them down into clear themes. In a study by Kessler et al (1), best presentation design includes ‘manageable scope of content’ and ‘clear objectives’.  Most audience will not remember more than 3-5 themes (2) so she needs to emphasize the specifically selected aspects of her presentation.

2.  Build in active elements to increase learning
Students actively involved in the learning activity will learn more than passive recipients (3). Interaction also improves problem-solving, decision-making and communication (4).

Attention decays every 15-18 minutes (probably shorter even for Emergency practitioners!). For a 60-minute talk, Dr. Xiu should try to insert one interactive activity every 20 minutes.

Interactive exercises can be used with groups or individuals. Dr. Xiu needs to tie these activities to the objectives and themes. For her session, examples could include:

  1. Brainstorming: Start with a cardiac arrest case. She could bring a few learners up to the blackboard or flip chart to write down their management at the start of lecture.
  2. Audience Response System: She could build in multiple-choice questions in the lecture using free softwares such as Poll Everywhere or Socrative.
  3. Role play: Dr. Xiu can have learners role play (paramedic/ER resident/nurse/family member/ICU resident) clinical scenarios to highlight learning points and develop decision making in various contexts.
  4. Flipped Classroom with active learning activity in class: She could also use the flipped or reverse classroom model by assigning the reading materials beforehand and using class time for interactive activities (5). It is critical that she prime her students. Her students need to understand that there will not be a didactic lecture in class, and they must do their pre-reading of core materials to be ready for class. They are responsible for teaching one other. If the students do not do their pre-reading, they will be behind everyone else. (See Figure 1 & 2 for helpful schematics for how the flipped classroom works along Bloom’s taxonomy.)


Figure 1+2-MEdIC1.12


For example, she could assign each learner to read one of 5-6 studies or papers about therapeutic hypothermia. During class they could form teams to debate on controversies about cooling or work in teams to create an algorithm for cooling patients.  They could then compare their results with existing hospital algorithms afterwards to see which is the closest. (A little competition always encourages engagement.) Table 1 contains other suggestions for activities.

Absentee Audience

To summarize the take-home points, Dr. Xiu could increase active engagement and attendance at her teaching sessions by using interactive strategies such as refining their management of a case that they committed to at the beginning of class, producing evidence-based algorithms, or holding debates and voting on the winning teams. Candy prizes don’t hurt either!



  1. Kessler CS, Dharmapuri S, Marcolini EG. Qualitative Analysis of Effective Lecture Strategies in Emergency Medicine. Ann Emerg Med. Elsevier Inc; 2011 Nov 1;58(5):482–7.
  2. Copeland HL, Longworth DL, Hewson MG, Stoller JK. Successful lecturing: a prospective study to validate attributes of the effective medical lecture. J Gen Intern Med. 2000 Jun;15(6):366–71.
  3. Butler JA. Use of teaching methods within the lecture format. Med Teach. 1992;14(1):11–25.
  4. Snell L, Steinhart Y. Interactive lecturing: strategies for increasing participation in large group presentations. Med Teach. Informa UK Ltd UK; 1999;21(1):37–42.
  5. Sherbino J, Chan T, Schiff K. The reverse classroom: lectures on your own and homework with faculty. Can J Emerg Med. 2013 May 1;15(3):178-80. Pubmed
  6. Chan T. “The reverse classroom” [PDF] What Works Presentation, International Conference on Residency Education, 2012. Presented October 19, 2012.  Ottawa, ON, Canada. Accessed last on May 19th, 2014.

Other useful sites for activities for the flipped classroom:

The Case of the Absentee Audience: Curated from the Community

During the extensive conversation, there were many pearls of wisdom that were traded amongst teachers and learners of various backgrounds. Of note, the following are some of the common themes that seemed to emerge from the comments.

Both parties must take responsibility for learning
The ALiEM community identified that teachers and learners must share responsibility for ensuring the success of any lecture. When both parties respect this responsibility, great learning opportunities arise. The community identified the following qualities of the responsible teacher and learner.


The responsible teacher knows the level of the learner, identifies goals, and facilitates progression. She understands where her own content fits into the overall curriculum. She is invested in learners and identifies relevant stressors in personal and professional spheres that may compromise the learning environment. Her in-depth knowledge of her content facilitates flexibility and adaptation to learner needs and interests. The responsible teacher has an enthusiasm for the material and passion for teaching.


The responsible learner engages, regardless of the format or style of material delivery. He is invested in the content and comes prepared to learn and contribute. He is intrinsically driven but he also responds to extrinsic motivators when created by a teacher he trusts. The responsible learner understands that the classroom has limitations and extends his learning to contextualized (e.g., clinical) learning environments. He is forgiving and is enthusiastic both about the material and about learning. The responsible learner engages in a partnership with his teacher that allows him to be flexible and adapt to new teaching styles. He is forgiving when these teaching styles are not as productive as planned.

Training and practice are important for success

The ALiEM community highlighted the need to seek out opportunities for professional development. Medical professionals are given formal training in most other aspects of their careers; the consensus was that teaching should be no different.  Formal training for both faculty and residents is ongoing at some, but not all, centers. A number of resources for improving presentations were suggested (see resources).

Other tips included:

  • Identify lecturers that you like, appreciate their style, but develop your own. Seek out mentors in those who you admire. (Chan, Swaminathan, Choo)
  • Get formal coaching. (Chan, Choo)
  • Practice your talks beforehand, preferably with a brutally honest critic. (Luckett,  Hensley)
  • Have a colleague watch you. (Swami, Siedsma)
  • Practice, reflect, adapt and keep at it. (Swaminathan, Gibson)

Draw from a diverse toolkit
Community members highlighted that there are ways to make classroom sessions more engaging:

  • Invite people down to the front (Hicks); flip the classroom if you are limber enough and confident enough to do it welll (Chin, Kobner, Macias, Brazil, Gibson, Hicks, Hensley)
  • Interact with, and respond to, the audience, which may require diversions from your planned lecture. (Brazil, Swaminathan, Hicks, Hensley, Mukherji)
  • Break the room into teams and make it a competition. (Mukherji, Luckett)
  • inject fun breaks or, if appropriate for the material, think about running a workshop or simulation instead of using a lecture format. (Chin, Hensley, Benítez)

Three pro tips for handling a low turnout at your lecture
by Christopher Hicks (@Humanfact0rz)

  • Step 1: “Invite everyone down to the front of the class.” Don’t let learners linger in the back rows.
  • Step 2: “Interact—confess that the lecture was planned for a larger group, but suggest you change it up. Seek input [from the learners in attendance].”
  • Step 3: “Up the interaction—more discussion, less lecture.”

Technology can engage and disengage learners
There were differences of opinions and experiences with incorporating versus “banning” technology to encourage student engagement (Murray, Brazil, Swami, Gibson, Luckett, Rogers). Some suggested that live tweets/audience polls might provide the presenter with real time feedback (Keefe). Javier Benítez summarized: “Technology can be a great aid to learning, if used appropriately, but pedagogy should come first.”

Teaching metacognition might help
Reasons for absenteeism by learners include “I already know this material,” and “I don’t think that I’m going to learn anything” [1]. Discussion from the ALiEM community suggested that metacognition in learners is quite poor, which means self-evaluation of what one knows and what one does not know is often inaccurate. Explicit teaching around, and assessment of, metacognition are important next steps in medical education (Purdy, Luckett, Gibson, Siedsma) A focus on metacognition by both parties may improve learner engagement and teacher performance.

The jury is still out on non-traditional methods
A number of non-traditional methods were discussed, including using television episodes and interpretive dance*. Teachers are finding ways to be creative; sometimes it works and sometimes it’s a flop. But as Michelle Gibson pointed out we “have to be prepared to fail”.

* Please note the consensus on interpretive dance was, that while entertaining, it might not actually be a great way to relay medical concepts. At this time, it cannot be endorsed as a valid evidence-based education intervention. Since we hope someone can prove us wrong we will continue to re-evaluate this lecture option moving forward. Please pass along any evidence you may have, preferably in video form.


  1. Clay T,  Breslow L. (2006). Why students don’t attend class. MIT Faculty Newsletter; XVIII(4). Accessed online at  on July 29, 2014.


Suggested Resources
There were a lot of very great resources that were suggested by our community this month. Here is collection of the resources mentioned by the ALiEM Community at some point during this week’s discussion.

Presentation resources

Medical Education Blog Posts (from FOAM and beyond)

Lingo for Learners
This month we found that there was a very sophisticated and high level debate, but as a learner, there seemed to be a lot of education lingo (e.g. edu-speak) that may not have been familiar with everyone.  The following are some key links to define the terms that may help others to get to know some of the key terminology mentioned in this discussion.

Key #MedEd Concepts from the Discussion
6 Steps for Curriculum Development (Kern) – a primer from UCSF
Active learning strategies:
Banking Education
Community of practice
Expertise reversal
Problem-based learning
Social constructivism
Situated learning environments

Thank-you to all the participants

All of the community participants (in alphabetical order) that participated in our discussions this week were:

Javier Benítez (@jvbntz)
Victoria Brazil (@SocraticEM)
Teresa Chan (@TChanMD)
Alvin Chin (@AyIC1989)
Esther Choo (@choo_ek)
Petra Dolman (@petradMD)
Erik Handberg (@ErikHandberg)
Chris Hicks (@HumanFact0rz)
Sarah Luckett Gatopoulos (@SLuckettG)
Michelle Gibson (@MCG_MedED)
Justin Hensley (@EBMGoneWild)
Bernadette Keefe (@nxtstop1)
Scott Kobner (@skobner)
Matt Klein (@MKleinMD)
Michael Macias
Pik Mukherji (@ercowboy)
Heather Murray (@HeatherM211)
Eve Purdy (@purdy_eve)
Todd Raine (@RaineDoc)
Rob Rogers (@EM_Educator)
Sameed Shaikh (@SynthShaikh)
Matt Siedsma (@matt_siedsma)
Nicole Swallow (@doc_swallow)
Anand Swaminathan (@EMSwami)
Manrique Umana (@umanamd)

Case and Responses Available for Download

Click Here (or on the picture below) to download the case and responses as a PDF.

1.12 mini MEdICs Copy

Author information

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan

The post MEdIC Series: The Case of the Absentee Audience – Expert & Community Commentary appeared first on ALiEM.

Social Media in the EM Curriculum: Annals of EM Resident Perspective article

Hand holding a Social Media 3d SphereThis month marks our second ALiEM-Annals Resident’s Perspective discussion. Similar to the ALiEM-Annals Global EM Journal Club series and the first Resident’s Perspective piece on Multiple Mini Interviews, we will be discussing the most recent Annals of Emergency Medicine Resident’s Perspective piece on the Integration of Social Media in Emergency Medicine Residency Curriculum. We hope you will participate in an online discussion based on the paper summary and questions below from now through August 1, 2014. Respond by commenting below or tweeting using the hashtag #ALiEMRP.


Google Hangout with the Authors

On July 31, 2014, we will be hosting a 30 minute live Google Hangout on Air with Drs. Kevin Scott (@K_ScottMDand Mira Mamtani (@MiraMamtaniPenn), the authors of the Annals of Emergency Medicine Resident’s Perspective paper on the how social media is being used in the EM educational curriculum. Also joining will be Drs. Stella Yiu (@Stella_Yiu), Michael Gisondi (@MikeGisondi), and Seth Trueger (@MDAware). Be sure to tune in! Later this year, a summary of this blog- and Twitter-based discussion will hopefully be published back into the journal.

  • 00:00 Bryan Hayes makes introductions
  • 01:06  Kevin Scott discusses the impetus for writing this paper.
  • 05:40  Mira Mamtani discusses (1) how to engage faculty in the use of social media technologies in residency education and (2) how this fits in with ACGME standards
  • 09:45  Stella Yiu talks about the flipped classroom and tips for success
  • 12:39  Seth Trueger talks about the role of social media in academia as well as about quality assurance
  • 15:05  Michael Gisondi talks about innovative practices at his institution and how to overcome barriers in bringing in “more senior” faculty.
  • 21:23  Wrap up final points and comments by the panelists

Twitter Feed with #ALiEMRP

Annals of EM Resident Perspective Article

Scott KR, Hsu CH, Johnson NJ, Mamtani M, Conlon LW, DeRoos FJ. Integration of Social Media in Emergency Medicine Residency Curriculum. Ann Emerg Med. 2014 Jun 21. [early release] PMID: 24957931. Free PDF download (2.1 MB)



This article is excellent overview of the current landscape of social media use and perspectives specifically in the graduate medical education world of EM. The authors, based in the University of Pennsylvania, share not only an introduction to social media and examples of best practices in medical education, but more importantly discuss the several barriers to more mainstream adoption of digital technologies.

Modalities and concepts discussed included:

  1. Blogs
  2. Podcasts
  3. Videocasts
  4. Twitter
  5. Google Hangout
  6. Flipped classrooms

Barriers discussed included:

  1. Generational gaps may lead to a lack of familiarity with social media
  2. Social media, such as Twitter, may cause a distraction and disrupt other aspects of residency education
  3. Core knowledge is currently less represented in social media content
  4. Residents may over-rely on social media education without critically appraising the literature
  5. Quality assurance is a constant concern amongst educators because social media resources, such as blogs, typically lack peer review before publication
  6. Learners may be overwhelmed by information overload using social media
  7. There is no validated study showing an objective improvement in resident knowledge and learning with social media
  8. As with everything in social media, privacy and professionalism issues are an underlying concern

FOAM Discussion to Date

The role of social media in the future of medical education is one of the most discussed topics among educators and students in the FOAM community. A comprehensive review of content produced since 2013, accomplished using FOAMSearch and Google queries, revealed 10 blog posts, 4 podcasts, and 2 open access journal articles discussing the role of social media in emergency medicine education. These resources, listed below, are a great overview of the many perspectives already shaping the role of social media in medical education. For those new to the idea of FOAM and social media in academia, be sure to check out Chris Nickson’s overview of FOAM at Life in the Fast Lane.

Academic Life in Emergency MedicineNew AIR Series: ALiEM Approved Instructional ResourcesAndrew GrockBlogUSA7/16/14
The Rolobot Rambles#FOAMed and #SMACC: Revealing the Camouflaged CurriculumDamian RolandBlogUnited Kingdom7/1/14
The Poision ReviewMust-read: getting started in online emergency medicine education and FOAMedLeon GussowBlogUSA6/28/14
Emergency Medicine CasesSocial Media & Emergency Medicine LearningAnton HelmanPodcastCanada6/24/14
Emergency Medicine CasesBest Case Ever 25 Rob Rogers on Social Media in EM EducationAnton HelmanPodcastCanada6/18/14
Ultrasound PodcastSocial Media and Medical Education. #FOAMED talk from #ACEP13Matt DawsonPodcastUSA5/14/14
ACEP NowTweets from Emergency Medicine-related Conferences Relay Latest Research About Social Media and Critical Care, Resuscitation Procedures, Ultrasounds, and ToxicologyJeremy FaustBlogUSA5/7/14
The Skeptics Guide to Emergency MedicineTiny Bubbles (#FOAMed and #MedEd)Ken MilnePodcastCanada4/25/14
Emergency Physicians MonthlyPRO/CON: Why #FOAMed is NOT Essential to EM EducationNicholas GenesBlogUSA4/7/14
Emergency Physicians Monthly
PRO/CON: Why #FOAMed is Essential to EM Education
Joe LexBlogUSA4/7/14
TakeokunResident Education in Ultrasound Using Simulation and Social Media AIUM14Jason NomuraBlogUSA4/2/14
iTeachEMHow we are flipping EM educationRob CooneyBlogUSA1/15/14
AAEM/RSA BlogFOAM — This is not the future of medicine, it is medical education NOW!Meaghan MercerBlogUSA7/23/13
Emergency Medicine NewsNews: How Twitter Can Save a LifePaul BufanoOpen Access JournalUSA4/12/13
FOAMed appeal is simple: Get more, pay nothing
Jeremy FaustBlogUSA2/1/13
Emergency Medicine NewsBreaking News: Don't Call It Social Media: FOAM and the Future of Medical EducationGina ShawOpen Access JournalUSA2/1/13
Academic Life in Emergency MedicineLost in translation: What counts as asynchronous learning?Nikita JoshiBlogUSA1/18/13



Featured Discussion Questions

The ALiEM team poses the following questions to explore current practices with social media and medical education, and perceptions about the benefits and drawbacks of this educational modality. If you have additional questions, feel free to pose them!

  • Q1. Educators: What are the biggest barriers for educators and how to overcome them?
  • Q2. Learners: How do we engage learners once the tech-innovation is employed? If you build it, they won’t necessarily come!
  • Q3. Programs: What are other examples of actual or potential innovations in GME that wasn’t described in the paper?

Please participate in the discussion by answering either on the ALiEM blog comments below or by tweeting us using the hashtag #ALiEMRP. Please denote the question you are responding to by starting your reply with Q1, Q2, or Q3.



Best Blog and Tweet

NEW! Contest for Best Blog Comment and Tweet

Thanks to Dr. Henry Woo and his colleagues in the Twitter-based International Urology Journal Club series (#urojc) hosted by @IUroJC, we are also implementing a contest for the Best Blog Quote and Best Tweet. What, emergency physicians – competitive? No… The winners will be announced in our Annals of EM publication curating this discussion.


This blog post was co-authored by Michelle Lin, MD (@M_Lin) and Scott Kobner (@skobner).

Disclaimer: We reserve the right to use any and all tweets to #ALiEMRP and comments below in a commentary piece for an Annals of Emergency Medicine publication as a curated conclusion piece for this Resident’s Perspective publication. Your comments will be attributed, and we thank-you in advance for your contributions.


Author information

Bryan Hayes, PharmD
Bryan Hayes, PharmD
ALiEM Associate Editor
Clinical Assistant Professor, University of Maryland (UM)
Clinical Pharmacy Specialist, EM and Toxicology

The post Social Media in the EM Curriculum: Annals of EM Resident Perspective article appeared first on ALiEM.

I am Esther Choo – Researcher, Public Health Advocate, and Educator: How I Work Smarter

How I Work Smarter Logo

In the first post for the “How I Work Smarter” series, I called out Dr. Esther Choo (@choo_ek), because she is able to juggle so many interests and responsibilities flawlessly. She’s the principal investigator for a study, funded by the National Institutes of Drug Abuse, looking at a national computer-based intervention for women with substance use and interpersonal violence in the ED; Academic Emergency Medicine‘s first Senior Associate Editor for Social Media; and star presenter. Esther was kind enough to provide her best-practice tips for this ongoing series.

  • Esther ChooName: Esther Choo, MD MPH
  • Location: Providence, RI
  • Current job: Assistant Professor, Emergency Department, Warren Alpert Medical School of Brown University
  • One word that best describes how you work: Nocturnally
  • Current mobile device: iPhone 5s
  • Current computer: MacBook Pro

What’s your office workspace setup like?

I have the following:

  1. One analytic computer for data analysis that is separate from everything else: that’s my data brain and where I keep Personal Health Information (PHI)
  2. One separate computer that I use for my RCT, since the software and plug-ins only work on a PC
  3. My laptop, which does everything else.

I backup everything on SugarSync, so I can access my files everywhere. (The alcohol to the right is for champagne taps, not part of the productivity/efficiency plan.)

Choo Desk

What’s your best time-saving tip in the office or home?

I use the Dragon app on my phone to dictate long emails, parts of papers, or new ideas while I am walking on the treadmill, watching my kids play in the yard, or otherwise not near a computer, so I don’t lose the wording/thoughts/etc.

What’s your best time-saving tip regarding email management?

Cluster times for email at the beginning and end of the day, so it doesn’t dominate the whole day. Email can snowball, so a little benign neglect is key.

What’s your best time-saving tip in the ED?

Be kind to the ancillary staff: secretaries, med techs, supply guys, security. When you are crushed, these guys can make a lot of important stuff happen for you fast.

ED charting: Macros or no macros?

Macros, but cautiously: I have used them for typical patients with very common presentations (LBP, low-risk chest pain), individualized as needed.

What’s the best advice you’ve ever received about work, life, or being efficient?

  1. As much as possible, everything you take on should serve more than one purpose.
  2. As much as possible, everything you take on should be in line with your main goals and objectives and consistent with your values.
  3. If you have a hard time saying no, say “I’ll think about it.” Then go back and say no later with a decent explanation and an apology.

Is there anything else you’d like to add that might be interesting to readers?

I’m also an obsessive whiteboard person, but I use it for checklists. It keeps me on track by breaking down my workload into manageable pieces. My core research stuff is in the column on the right, and every day in the office I try to move at least one thing in that section forward. Once I finish a task, I check it off and leave it on for a week or two so I can have a sense of accomplishment.

Choo Whiteboard

Who would you love for us to track down to answer these same questions? (list up to 3 names)

  1. Deb Houry
  2. Lainie Yarris
  3. Zack Meisel


Author information

Michelle Lin, MD
ALiEM Editor-in-Chief
Editorial Board Member, Annals of Emergency Medicine
UCSF Academy Endowed Chair for EM Education
UCSF Associate Professor of Emergency Medicine
San Francisco General Hospital

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MEdIC Series | The Case of the Absentee Audience

LLSAslideHave you ever been at a lecture where the audience didn’t seem in ‘sync’ with the speaker?  Or perhaps as a junior presenter, some of you may have been at a lecture or two that just didn’t seem to work. This month, we ask you to advise Dr. Xiu, a presenter who is experiencing this exact problem. Come out and discuss the Case of the Absentee Audience.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in pdf format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Absentee Audience

by Teresa Chan (@TChanMD)

The view from the lectern was less than inspiring. Dr. Nelly Xiu, a newly appointed Associate Professor, stood in front of a half filled lecture hall. Of the nearly forty residents and medical students who were supposed to be at the Emergency Medicine conference day*, only about half were physically at the talk. Nelly viewed the learners, watching them pull out their computers, smart phones, and the occasional journal, and wondered if any of them were mentally present.

At the end of her lecture, the tepid applause from the audience further reinforced her impression. Nelly was surprised when the chief resident, Andrew Smith, came up to chat with her after her lecture.

“Hey Dr. Xiu, good talk. Therapeutic Hypothermia is a really important topic,” he started. “I was wondering if you’ve ever thought about doing this topic as a workshop instead?”

Nelly looked at him, perplexed by his question. Clearly the students and residents had been wholly disengaged with her lecture, couldn’t he see that?

“Andrew, this was a mandatory class, and only 20 of the 40 learners on our teaching unit came. And then the half that did come were too busy texting and emailing to listen.”

“Well, I don’t think that’s fair.  A bunch of them are post-call, some of them were still rounding with their attendings, and some of them were sick. You’re right – this is mandatory – but sometimes that isn’t enough to get people in seats anymore. And it’s definitely not enough to make sure they’re paying attention.”

Nelly pondered this thought for a moment. If the word mandatory wasn’t enough to ensure learner attendance and attention, then what would she need to do to reach her audience?

Key Questions

  1. Andrew says: “…sometimes that isn’t enough to get people in seats anymore. And it’s definitely not enough to make sure they’re paying attention.  Is he correct in his statement? Why or why not?
  2. What are some issues that occur when you make a session ‘mandatory’?
  3. As a teacher, are there any preventative measures that you can use to prophylax against an absentee audience?
  4. What are some strategies that you might advise Dr. Xiu to use in her future sessions?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This month the two experts are:

  • Dr. James Ahn (@AhnJam) is an emergency medicine physician in Chicago, IL. He is the associate program director and medical education fellowship director at the University of Chicago. His areas of interest include curriculum development and competency testing.
  • Dr. Stella Yiu (@Stella_Yiu) is an emergency physician in Ottawa, ON, Canada.  She is an assistant professor in the Department of Emergency Medicine at the University of Ottawa. She is the brains behind the Flipped EM Classroom.

On August 1, 2014 the Expert Responses and Curated Community Commentary for the Case of the Absentee Audience will be posted.  Please comment below to join in the discussion.  Your comments will help to form the basis for the curated community commentary.

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Author information

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan

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Child Whisperer Series: After the Pediatric Code Blue

mom_holding_baby_boy_400_clr_34534-168x300“We need to debrief” said the nurse manager after the medical team walked out of the critical care room after pronouncing a child who died after a traumatic accident. The social worker pointed at me (I am a Child Life Specialist) and looked at her and said “It’s our code blue now. We have to wait. We have a job to do”. Which was her way of saying we still had a lot of work to do with the family. At that point I walked in a room with the social worker and devastated parents, where the patient’s brother waited. He looked at me with big eyes and wanted to know if his sibling was ok. Not a conversation I would wish upon my worst enemy.

How do you support a family during the most horrible day of their life? How you do move on yourself when you have a job where you can’t tell anyone in your life about your day? How do you walk back into the hospital after a child has died on your watch?

No person in my life knows how many children I have said goodbye to, and I honestly am not sure myself. It has been too many. I’ve held siblings’ hands and cried with parents.  I’ve been strong and supported doctors when they have said, “there is nothing more we can do”.  I’ve been in the room with entire families while we watch their child slip away and seen the most brutal CPR on tiny fragile children. I have done handprints… so many handprints on children who have died. I hate handprints. But I do them, because I know how and the family needs me to. 

A very wise social worker said to me once:

There is a point in our care where we have to give the family back to their family and friends, it’s our job to give them as much support and as many tools as we can so that they can survive after we do our job and give them back.

When my job is done, I’ve hugged the parents, made the proper referrals, and sent them home with their families. I’ve got to go back to work. I’ve had moments where a death has had no effect on me, and I think my heart has turned to stone. I have also had moments where I felt like saying screw this place, call my manager, and get myself sent home. However, more times than not,  I’ve taken a few minutes and gone on walks and cried my eyes out. I’ve gone to a favorite social worker or a friend at work and talked it out. I can’t tell my husband or family about it, because I love them too much to give them that visual… and they just wouldn’t understand.

My advice is simple. Take care of yourself, and walk away from every situation knowing that you have done everything in your power to help someone through the most difficult day of their life. That means something. It has to.

Author information

Kristen Beckler, CTRS, CCLS
Kristen Beckler, CTRS, CCLS
Certified Child Life Specialist
Lucile Packard Children’s Hospital at Stanford
Pediatric Emergency Department

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Diagnose on Sight: Bilateral Leg Rash

Erythema Nodosum

Case: A pre-teen girl, living in central California, recently started on fluconazole, now presenting with a bilateral leg rash. What is your diagnosis? Click on the image for a larger view.




Erythema nodosum, secondary to coccidioidomycosis


Erythema nodosum is a cutaneous reaction consisting of inflammatory, tender erythematous subcutaneous nodular lesions. The classically painful rash is located on the lower extremities and usually regresses spontaneously. It is associated with a wide variety of disease processes [1,2] including:

  • Most common cause: Streptococcal infections
  • Other causes:
    • Behcet’s syndrome
    • Oral contraceptive use
    • Pregnancy
    • Sarcoidosis
    • Tuberculosis
    • Viral infections

Coccidioidomycosis is endemic to certain arid parts of the Southwest United States. Erythema nodosum is the most characteristic reactive cutaneous manifestation of coccidioidomycosis. It presents 1-3 weeks after onset of illness and is usually self-limited [3]. While strep infections are the most common cause of erythema nodosum, in a patient who has recently visited the American southwest, suspect coccidioidomycosis.


Master Clinician Bedside Pearls

Stuart Swadron, MD




Stuart Swadron, MD – Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California (provided to ALiEM and recorded by Swadron, 2014)



  1. Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol. 2000;19(3):212-6. PMID: 10870657.
  2. Schwartz R, Nervi S. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007 Mar 1;75(5):695-700 PMID: 17375516.
  3. DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol. 2006 Dec;55(6):929-4.2 PMID: 1711021.

Author information

Jeff Riddell, MD
Jeff Riddell, MD
Chief Resident
UCSF-Fresno Emergency Medicine Residency

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