BoringEM: We Need Your help – Digital Scholarship Elective

Digital Scholarship & the Scholarship of Teaching

Editor’s note: Alia Dharamsi is a PGY1 from the University of Toronto. She will be completing the first ever Digital Scholarship Elective with myself (Dr. Teresa Chan) & Dr. Andrew Petrosoniak this December.  The following is a write up by Alia that describes her intended experience, and then we have a small favour to ask of you at the end…. (SPOILER: She has as short survey you can help her complete… CLICK HERE TO GO TO THE SURVEY.)

– Teresa Chan

The Question:
As social media garners more momentum in the realm of medical education, how can I as an Emergency Medicine Resident learn how to teach effectively online?

Background:
What is the role of Social Media in Emergency Medical Education?

Digital media has become the next frontier in medical education, and has grown exponentially over the past few years as new technologies in knowledge translation become available. Recently, a study of 226 Emergency Medicine residents demonstrated that 98% of those interviewed used some form of social media for learning, including blogs, podcasts, vodcasts, Twitter, and Google Hangouts (Scott, 2014). Additionally, a study done in the USA showed that Emergency Medicine residents prefer listening to podcasts (70%), over reading textbooks (54.3%), for their learning (Mallin, 2014).

The idea of “asynchronous education”—that learners can use recent patient encounters or prompts to guide their supplemental reading and learning—is garnering more and more attention. Asynchronous education allows a variety of modalities of teaching, including peer-to-peer learning, which are student centered, and shown to be not only preferred by learners, but also more effective (Mallin, 2014). Although new to the medical education world, asynchronous education has been adopted into other educational sectors to great success. The Khan Academy is arguably one of the most successful applications of digital technologies to advance personalized education, in the model of the “flipped classroom.” As described by Prober et. al.(2013), the flipped classroom employs digital technologies to allow students to watch vodcasts (online videos) on their own time, as many times as needed to achieve mastery, then utilize classroom time to apply said learning. To that effect, these technologies are providing residents with resources to personalize their clinical learning, and achieve mastery on their own time, can create a flipped-classroom type experience on the wards and in the Emergency Department, as with the guidance of clinician teachers they would be able to apply their knowledge to patient care. (Prober, 2013)

The Plan: A Digital Scholarship Elective

This Digital Scholarship block provides me with an opportunity to explore the fundamentals of curriculum design, in the context of my existing interests in social media and digital educational resources. Using antibiotic choices as a theme (a self-identified area of clinical weakness), I am spending one month developing a mini-curriculum on common presentations of infection to the ED, and an approach to antibiotic choices.

For this project, I will be moving through the 6 steps of curriculum development, as defined by Kern et al.:

  1. Problem identification and general needs assessment
  2. Needs assessment for targeted learners
  3. Goals and Objectives
  4. Educational strategies
  5. Implementation
  6. Evaluation and feedback

Through this elective I will be able to better understand medical education and the process of curriculum development, as well as hopefully create some resources around antibiotic choices in the ED that fellow learners will find useful.

The Product: Social Media based curriculum on antibiotic choices in the ED

Designed for the medical student and junior resident level, this curriculum will be predominantly online-based, including short chalk talks, blog posts and pocket cards on 5 common outpatient infectious disease presentations to the ED:

  1. Community acquired pneumonia
  2. UTI
  3. STI
  4. Skin and soft tissue infections
  5. Diabetic foot

Hosted on BoringEM.org, where the majority of viewers are learners in Emergency Medicine, I will be able to receive peer review and feedback on these resources once they are posted.

References

Cadogan M, Thoma B, Chan TM, et al. Emerg Med J Published Online First: [ 04 September 2014] doi:10.1136/emermed-2013-203502.

Kern DE, et al. Curriculum Development for Medical Education- A Six-Step Approach. Baltimore. Johns Hopkins University Press. 1998.

Mallin, Mike, Sarah Schlein, Shaneen Doctor, Susan Stroud, Matthew Dawson, and Megan Fix. “A Survey of the Current Utilization of Asynchronous Education Among Emergency Medicine Residents in the United States.” Academic Medicine 89.4 (2014): 598-601. Web.

Prober, Charles G., and Salman Khan. “Medical Education Reimagined.” Academic Medicine 88.10 (2013): 1407-410. Web.

Scott KR, Hsu CH, Johnson NJ, Mamtani M, Conlon LW, DeRoos FJ. “Integration of Social Media in Emergency Medicine Residency Curriculum.” Annals of Emergency Medicine (2014): n. pag. Web.

Thoma, B., Chan, T., Desouza, N., & Lin, M. (2013). Implementing peer review at an emergency medicine blog: bridging the gap between educators and clinical experts. CJEM, 16, 21-24.

How you can help:

Alia Dharamsi is a PGY1 in Emergency Medicine at the University of Toronto, conducting a quality improvement project with BoringEM on the application of social media technologies to resident learning. This project has been granted REB exemption from the Hamilton Integrated REB (HIREB).

She is exploring resident comfort, knowledge around antibiotic choices, and their usage resources to guide choice of antibiotics at the bedside.

The main objective is to understand current patterns of use of resources to learn about antibiotic choices before, after, and during an ED shift, and then see if social media learning materials (e.g. #FOAMed) has a role in filling knowledge gaps for learners.

This survey is SHORT (5 minutes), anonymous, and voluntary. She is specifically interested in answers from junior residents (R1, R2), and CC4s.

CLICK HERE TO GO TO THE SURVEY.

Please feel free to share with your residency program.

Author information

Alia Dharamsi
Alia Dharamsi

The post BoringEM: We Need Your help – Digital Scholarship Elective appeared first on BoringEM and was written by Alia Dharamsi.

Boring Question: Does my patient require admission for IV antibiotic administration?

We have all had a patient or two request admission for intravenous antibiotics. Usually, the argument is that IV administration is better because it ‘gets into the blood more quickly’. In fact, many of us have made that argument ourselves, or heard it from our peers.1024px-ICU_IV_1

But, what if I told you that many of your favourite antibiotics have similar pharmacokinetic properties regardless of the route of administration? What if I also showed you that patient outcomes don’t change much, regardless of whether you choose oral or intravenous administration? What if you knew that intravenous antibiotics (usually several dollars per dose) are significantly more expensive than oral (usually pennies per dose)?

Well, brace yourself, because levofloxacin [1], ciprofloxacin [2],clindamycin [3], and amoxicillin [4]
are all rapidly absorbed when taken orally; in fact, each of these antibiotics has similar pharmacokinetics across oral and intravenous routes. Additionally, though there is no evidence comparing PO to IV azithromycin, the package insert [5] suggests a higher concentration for the first 24 hours with use of the IV version of the drug; the clinical relevance of this fact is yet to be determined.

The Evidence

If an antibiotic has similar bioavailability regardless of route, the route of administration should not affect clinical outcomes. So let’s examine so evidence:

Children with Pneumonia

In one trial that included tertiary care centres in Africa, Asia, and South America [6], 1702 children aged 3-59 months were admitted with pneumonia, and randomized to receive either PO amoxicillin or IV penicillin for 48 hours. If they improved clinically, children in either treatment arm were discharged home with a five-day course of oral amoxicillin. Treatment failure was 19% in both arms. This study was reproduced on a small scale in England in 2010 [7]. Two hundred thirty-two children were again randomized to PO amoxicillin or IV penicillin. Similar results were obtained, with the additional finding that children receiving IV antibiotics had longer stays in hospital (3.12 vs 1.93 days) and IV treatment was more expensive (£1256 vs £769).

Adults with Lower Respiratory Tract Infection

In one study in Dublin, Ireland [8], 541 adult patients were admitted for lower respiratory tract infection were randomized to one of three conditions: PO amoxicillin-clavulinic acid; IV amoxicillin-clavulinic acid transitioning to PO; or an IV cephalosporin transitioning to a PO cephalosporin. The researchers found no significant differences in clinical outcome or mortality among the three groups. Lengths of stay were 6, 7, and 9 days respectively.

Adults & Children with Severe Urinary Tract Infections

A Cochrane Review in 2008 [9] was unable to find evidence to support the superiority of IV antibiotic treatment over oral both adults or children.

Dare we Choose More Wisely?

Early conversion to PO antibiotics on the wards can lead to significant cost savings. The evidence reviewed here suggests that these savings do not come at the expense of safety. The CDC has gathered a nice collection of papers here [10]. The most recently cited study suggests $4,404 savings from decreased utilization of radiology, laboratory, pharmacy, and room costs. Costs in the United States can vary widely among hospitals, but the message is clear: Oral antibiotics save money without comprising effectiveness.

Conclusion

Next time you prescribe antibiotics in the emergency department, start the patient off right. Provide an oral dose of an appropriate antibiotic, whenever possible. You will set the course for a shorter, less expensive hospital stay for your patient without compromising his or her safety. Reigning in costs for both the system and patient as well as providing evidence-based care is at the crux of the Choosing Wisely Campaign.

Peer reviewed by Dr. Sarah Luckett-Gatopoulos (@SLuckettG) and staff reviewed by Dr. Teresa Chan(@TChanMD)

References

  1. Fish, D. N., & Chow, A. T. (1997). The clinical pharmacokinetics of levofloxacin.Clinical pharmacokinetics, 32(2), 101-119.
  2. Lettieri, J. T., Rogge, M. C., Kaiser, L., Echols, R. M., & Heller, A. H. (1992). Pharmacokinetic profiles of ciprofloxacin after single intravenous and oral doses. Antimicrobial agents and chemotherapy, 36(5), 993-996.
  3. Bouazza, N., Pestre, V., Jullien, V., Curis, E., Urien, S., Salmon, D., & Tréluyer, J. M. (2012). Population pharmacokinetics of clindamycin orally and intravenously administered in patients with osteomyelitis. British journal of clinical pharmacology, 74(6), 971-977.
  4. Spyker, D. A., Rugloski, R. J., Vann, R. L., & O’Brien, W. M. (1977). Pharmacokinetics of amoxicillin: dose dependence after intravenous, oral, and intramuscular administration. Antimicrobial agents and chemotherapy, 11(1), 132-141.
  5. http://labeling.pfizer.com/ShowLabeling.aspx?id=513#section-11
  6. Addo-Yobo, E., Chisaka, N., Hassan, M., Hibberd, P., Lozano, J. M., Jeena, P., … & Thea, D. M. (2004). Oral amoxicillin versus injectable penicillin for severe pneumonia in children aged 3 to 59 months: a randomised multicentre equivalency study. The Lancet, 364(9440), 1141-1148.
  7. Lorgelly, P. K., Atkinson, M., Lakhanpaul, M., Smyth, A. R., Vyas, H., Weston, V., & Stephenson, T. (2010). Oral versus iv antibiotics for community-acquired pneumonia in children: a cost-minimisation analysis. European Respiratory Journal, 35(4), 858-864.
  8. Chan, R., Hemeryck, L., O’Regan, M., Clancy, L., & Feely, J. (1995). Oral versus intravenous antibiotics for community acquired lower respiratory tract infection in a general hospital: open, randomised controlled trial. BMJ,310(6991), 1360-1362.
  9. Pohl, A. (2008). No evidence that oral antibiotic therapy is less effective for treating urinary tract infection than intravenous antibiotics.  Cochrane Summaries, available at: http://summaries.cochrane.org/CD003237/no-evidence-that-oral-antibiotic-therapy-is-less-effective-for-treating-urinary-tract-infection-than-intravenous-antibiotics
  10. http://www.cdc.gov/getsmart/healthcare/support-efforts/asp-int-costs.html

Author information

Patrick Bafuma
Patrick Bafuma

The post Boring Question: Does my patient require admission for IV antibiotic administration? appeared first on BoringEM and was written by Patrick Bafuma.

KT Evidence Bites: ProCESS

Editor’s note: This is a new series based on work done by three physicians (Patrick Archambault, Tim Chaplain, and our BoringEM Managing editor Teresa Chan)  for the Canadian National Review Course (NRC). You can read a description of this course here.

The NRC brings EM residents from across the Canada together in their final year for a crash course on everything emergency medicine. Since we are a specialty with heavy allegiance to the tenets of Evidence-Based Medicine, we thought we would serially release the biggest, baddest papers in EM to help the PGY5s in their studying via a spaced-repetition technique. And, since we’re giving this to them, we figured we might as well share those appraisals with the #FOAMed community! We have kept much of the material as drop downs so that you can quiz yourself on the studies.

Paper: A Randomized Trial of Protocol-Based Care for Early Septic Shock

Citation: N Engl J Med. 2014 May 1; 370(18):1683-93. Epub 2014 Mar 18. PMID: 24635773

Nickname of study: ProCESS study

Summarized by: Patrick Archambault
Reviewed by: Teresa Chan & Tim Chaplin

Rationale for Study

1) Is protocol-based resuscitation better to usual care?

2) Is a protocol with central hemodynamic monitoring to guide the use of fluids, vasopressors, blood transfusions, and dobutamine (“Early Goal Directed Therapy”) better than a simpler protocol that does not include these elements?

Clinical Question

In patients with septic shock presenting to the ED, is a …

  1. catheter-based goal-directed resuscitation protocol better than
  2. usual care or a
  3. simplified goal-directed resuscitation protocol?
PopulationIn patients with septic shock presenting to the ED, is a catheter-based goal-directed resuscitation protocol better than usual care or a simplified goal-directed resuscitation protocol?
InterventionCatheter-based goal-directed sepsis protocol
Controla) Simplified goal-directed sepsis protocol

b) Practice as usual (no prompts by study coordinator and bedside physicians were not trained to deliver EGDT or protocol-based standard therapy)
Outcome1) hospital mortality rate at 60 days
2) mortality rate at 90 days
3) cumulative mortality at 90 days and 1 year
4) secondary outcomes (length of cardiovascular, respiratory, renal failure, length of hospital and ICU stay, discharge disposition)

Methods

RCT: outcome assessment was blinded but not healthcare professionals, intention to treat analysis

Results

1) Fluid administered in the first 6 hours was significantly different between groups (P<.001):

  • EGDT: 2.8L
  • protocol-based standard care: 3.3L
  • usual-care: 2.3L

2) Dobutamine use was significantly different between groups  (P<0.001):

  • EGDT: 8.0%
  • protocol-based: 1.1%
  • usual care 0.9%

3) Packed Red Blood Cells was significantly different between groups (P = 0.001):

  • EGDT: 14.4%
  • protocol-based: 8.3%
  • usual care: 7.5%

4) Primary outcome: 60 day mortality (P=.55 for three way comparison)

  • EGDT: 21.0%
  • protocol-based 18.2%
  • usual care: 18.9%

5) No differences in other primary endpoints.

6)  Secondary outcomes: Need for Renal replacement Therapy was higher in protocol-based standard care (P=0.04)

  • protocol-based: 6.0%
  • EGDT: 3.1%
  • usual-care: 2.8%

Conclusion

1) There is no significant advantage, with respect to mortality or morbidity, of protocol-based resuscitation over bedside care that was provided according to the treating physician’s judgment

2)  There is no significant benefit of the mandated use of central venous catheterization and central hemodynamic monitoring in all patients

Take Home Point

ProCESS identifies early recognition of sepsis, early administration of antibiotics, early adequate volume resuscitation, and clinical assessment of the adequacy of circulation as the elements we should focus on to save lives.

EBM Considerations

1) 10 years after the original EGDT Rivers study, the usual-care group has changed and has potentially integrated principles of the EGDT protocol, early recognition of sepsis, early antibiotics, lower tidal volumes, tighter blood sugar control.

2) We don’t know if randomization was concealed.

3) The EGDT group seemed sicker at baseline (more abdominal sepsis, lower BP, longer time to randomize) .

4) External applicability: these were all academic centers, a full research team prompting clinicians to act and follow time sensitive protocols (a study coordinator, bedside nurse and a dedicated research physician).

To download a copy of this summary click here.

 

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post KT Evidence Bites: ProCESS appeared first on BoringEM and was written by Eve Purdy.

#CanFOAMed goes SMACC

It’s certainly an exciting time for Social Media teachers and learners. The Social Media And Critical Care conference (#smaccUS) is coming to North America, and it’s been generating quite a buzz on our Twitter feeds this past week.

Digging into the conference program, we see quite a few Canadian superstars are helping out in the conference:

  • Teresa Chan
  • Pat Crosskerry
  • Sara Gray
  • Andrew Healey
  • Chris Hicks
  • David Juurlink
  • Sarah Luckett-Gatopoulos
  • Ken Milne (a.k.a. The SGEM, BatDoc)
  • Andrew Petrosoniak
  • Eve Purdy
  • Jonathan Sherbino
  • Brent Thoma
  • Stella Yiu

(NB: Please drop a comment below if you noticed someone is not on this list! I will amend to make it work!)

It is so exciting to see so many Canadians involved in this very international conference.  And I’m sure many of you will be there, but just might not be tied to any particular sessions.  So, in an effort to connect the Canadian contingent, we at BoringEM.org are posting this open survey and join a mailing list for Canucks @ SMACC.

P.S. We’re thinking about a T-shirt… and Eve Purdy is all over it already for a custom T-shirt.  Rupi Sahsi has also identified a good alternative on twitter already, so we have a great set of minds already coalescing on this topic.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #CanFOAMed goes SMACC appeared first on BoringEM and was written by Teresa Chan.

The 3 Biggest Challenges of Medical School… and how to overcome them

Getting into medical school is hard. According to recent statistics, both applicants and University enrollment have been increasing. medischool hardThe desire to become a doctor is at an all-time high and many claim that the hardest part of medical school is actually getting in. Whether or not that statement is true remains debatable. This article aims to give a short list of the hardest non-clinical struggles medical students have. As a subjective piece, some aspects will be omitted, and you are welcome to further the list in the comments below. So here are the 3 biggest challenges of medical school… and how to overcome them.

1. Medical Terminology

Daunting at first, the textbooks are ridden with words that look like they require a degree in Lexicology just to pronounce. Medical dictionaries the size of a Russian classical novel petrify freshmen in the libraries- and rightfully so, with over 250 roots, dozens of prefixes and suffixes – the combinations are plentiful. Yet everyone
agrees that knowing the vocabulary of medicine is absolutely crucial to effectively practicing the craft. Medical terminology is about as complicated as a language

Fortunately, it has rules that can be utilized to your advantage. Breaking down medical terminology to its building blocks will aid in formulating the definition, rather than just remembering it. A tried and tested method is flash cards – never underestimate their usefulness.

2. Workload

In addition to the highly complex, long and seemingly abstract terms, the volume of information students are required to know is dumbfounding, especially in the first two years. Having to learn most of human anatomy, pathophysiology, pharmacology and microbiology is a daunting task. In the moment, you may feel terror in your heart as you complete peer-medical termsreviewed presentations, clinical exams and worst of all – written exams.

You need to remember that others have gone through what you are experiencing. And they survived. Find out how. Ask third year and fourth year medical students how they prepared for exams. Did they approach the tutor directly? Do any of the lecturers share useful information in office hours? How were the hardest exams passed? You can follow my example and use post-it notes around the apartment. In my first year, I found that study groups were very helpful with the complex concepts. In addition, I would recommend that you take full advantage of different learning methods. Record your own voice, join discussions or watch online videos – whatever you deem best.

3. Motivation and Burnout

Remember the question “Why do you want to be a doctor”? Now if you look at yourself in the mirror – sleep deprived, tired, unmotivated, not having seen your family and friends for what seems to be eons – and you have difficulty answering that question, you may be suffering from burnout. Ishak et al. (2013) have found that more than half of all medical students will suffer from burnout. It is a serious and complex problem. Contributors include lack of appropriate mentorship, poor exercise habits, unhealthy diet, lack of sleep, lack of autonomy, stress in the work place, exposure to trauma etc. Most often it is a combination of issues. According to the AAMC the 4-year graduation rate is at its lowest rate, 81% in 2009, and has seen a continuous decline in the last 30 years.

burnout

With all the work you are expected to do, the pressures you feel from everyone around you and especially from yourself, it is easy to go into a state of overdrive. Talk to your friends and family. Often they will be the first to recognize that something is wrong. Listen to them when they are concerned. If you think it is appropriate, contact the student help center in your university. Never forget – you are the future of medicine and people care about your wellbeing. I cannot stress this enough: you need to care about your wellbeing first and foremost.

There are a few things that one can do to prevent burnout:

  • The first is related to motivation. I can suggest that you search for motivation from within. The BoringEM series #DearPreMed highlights the importance of ensuring that your motivations for medical school are intrinsic. As one of many studies suggests, intrinsic motivation is more lasting and brings about better results as compared to extrinsic motivation. The ALiEM bookclub discussion on Drive also focused on intrinsic motivation. Find out what excites you and what makes you happy about getting up in the morning or on the wards. Then find ways to be involved in those things.
  • Seek out mentorship. Find someone who can help you when times are tough or when you need to talk through a case and to keep you on track when things are going well.
  • Sleep well. Eat well. Work out. Laugh. Love. Don’t forget to take care of your body and to fill yourself up with friends and family. Schedule these in. Make them a priority.

Bottom Line

Getting into medical school is hard. Surviving the first 2 years of medical school is hard. Graduating from medical school is hard. But doctors have the privilege of caring for patients. That is not a responsibility that should be taken lightly. So yes, becoming a doctor is hard, but it’s also incredibly rewarding. Remember to find ways to feel those rewards every single day.

 

Reviewed by Eve Purdy

Author information

Anton Gervaziev
Anton Gervaziev

The post The 3 Biggest Challenges of Medical School… and how to overcome them appeared first on BoringEM and was written by Anton Gervaziev.

Medical Education at the ICRE Social Media Summit

On October 22, 2014, the Royal College of Physicians and Surgeons of Canada (RCPSC) hosted the world’s first Social Media (SoMe) Summit in Health Professional Education in Toronto, ON, Canada.  This conference preceded the annual International Conference on Residency Education (ICRE).

Eve Purdy, Heather Murray, Brent Thoma and I were very excited to take part in this event, especially since our online #FOAMed and #MedEd heroes were all participating:

  1. Michelle Lin (@M_Lin) – The mastermind behind ALiEM.com (COI: Brent & I are both Associate editors for her blog). See her plenary speech here.
  2. Anne Marie Cunningham (@amcunningham) – The Welsh social media guru herself, whom is behind the blog Wishful Thinking in Medical Education. See her plenary speech here.

Many of the top educators from Canada were present as well, including the likes of: Jason Frank, Jonathan Sherbino, Felix Ankel, Fiona Moss, Leslie Flynn, Elaine van Melle.

Of course, the #FOAMed masses also did come out to this event, and it was very exciting for me to discuss issues around online education with the likes of Seth Trueger, Heather Murray, Anton Helman, Stella Yiu, Ian Pereira, Ali Jalali, Eve Purdy, Jeff Hill, Rob Cooney… and so many more! (I apologize if I left you off, but I’m going off of my photos from my phone, so if I’ve left you off the list it’ll be because I don’t have your photo is all!)

Four concurrent sessions were held:

  • Concurrent session #1 –Ethical and professional  use of Social Media for health professional education – which explored ethical and professional issues using an appreciative inquiry model to guide the discussion.
  • Concurrent session #2 –Best practices for Social Media platforms – which used a modified Delphi technique to speedily rate 151 quality indicators for blogs and podcasts, based on previous work done by Brent Thoma et al. (DOI: I did help with this session!)
  • Concurrent session #3 – Defining and evaluating Social Media education scholarship
    – which utilized a more traditional format for consensus building, where the discussants (lead by J. Sherbino) proposed statements and opened up the discussion to the floor for commentary.
  • Concurrent session #4 –How education theory should inform Social Media – which explored interactions between educational theory and its intersection with modern social-media teaching and learning.

All in all, I know that I will be excited to see what comes out of the consensus conference proceedings papers (which will be published in the Postgraduate Medical Journal), and we will keep you up to date as we go forward about other new exciting news in the area of Social Media Scholarship. Rumour has it that there may be interest in holding yet another #SoMeSummit.  If there is, would you attend?  (Drop you answers below!)

 

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Medical Education at the ICRE Social Media Summit appeared first on BoringEM and was written by Teresa Chan.