Teaching Risk Taking Behavior in Medical Education

Swaminathan Headshot 2013

This post was put together by the incredibly talented and brilliant, Swami.




A 44-year-old healthy man presents with dull chest pain for 3 hours. His EKG is unremarkable. What’s his risk for acute coronary syndrome? Should he get a troponin? Two troponins? Observation and a stress test?

The Emergency Department is an inherently high-risk zone.

The Emergency Department is an inherently high-risk zone.

Emergency Medicine is an inherently risky specialty. In fact, many would say that risk stratification is our specialty. When a patient presents with symptoms, we use our clinical knowledge to determine what we think to be the most likely cause of those symptoms. We then apply studies and investigations to help confirm that diagnosis while attempting to “rule out” other diagnoses. At the end of this, we are often left without a specific diagnosis and need to make a disposition. When we decide to admit or discharge a patient, have them follow up in 24 hours or 1 week we are risk stratifying. For those we send home without a diagnosis, we try to determine how long they can wait to see another doctor for further investigation. We know that some of these patients will decompensate and return to the ED and so we are risk stratifying the likelihood of that decompensation.   Thus, during each patient encounter, the Emergency Physician needs to perform multiple risk stratifications. For example:   A 41-year-old man on aspirin presents with minor head trauma. His GCS is 15 and he is neurologically intact. He complains of a mild headache.

  • Does the patient need imaging now?
  • Does the patient need observation for 2 hours? 4 hours? Overnight?
  • Can I send the patient home safely without imaging?
  • Will the patient’s status degrade in the next 24 hours? 48 hours?
  • Should I schedule neurology follow up? If so, when?

This is a fairly simple case yet multiple risk assessments are involved. Each of these decisions must take into account hospital factors (i.e. ability to obtain follow up) and patient factors (i.e. distance from the hospital, reliable to follow up).   This brings us to the central questions of this post:

  • How do I train residents about risk?
  • How do I train residents to develop their risk threshold?
  • How do I train residents to embrace risk?
Damn it Jim, I'm a doctor not a CT scanner!

Damn it Jim, I’m a doctor not a CT scanner!

Clearly, we can see the need for this type of training. While we’d all like to have the magic tricorder to tell us if the patient has an intracranial injury, has a concussion etc we don’t. We deal with tests that are less than perfect and make decisions based on these tests.This raises the first point I always discuss with my residents. There is no such thing as a “rule-out” test. There is no test or series of tests that can definitely “rule-out” a disease. We use the tests to risk stratify the patient. Take another case:

A 22-year-old woman presents with right lower quadrant pain and vomiting. She is tender and you order a CT scan of the abdomen and pelvis. The scan is read as “no intra-abdominal pathology is identified that explains the patients pain.” Has the patient been “ruled-out” for appendicitis?

We know the answer to this question is no. CT scan of the abdomen and pelvis has a sensitivity of 98-99% and so there will be patients that are false negatives. In spite of the fact that we know this, we usually tell patients, “You don’t have an appendicitis. You’re going to be fine and we’ll be discharging you in a bit.” What we should be telling patients is “The CT scan doesn’t show signs of appendicitis. I think it’s unlikely you have an appendicitis but the test isn’t perfect. There’s still a chance. We’re going to send you home but here’s what you need to watch out for.” The second statement is an acknowledgement that we have risk stratified to a low risk category but not no risk. This approach goes for any patient we see whether it be chest pain, an ankle injury or abdominal pain. Although this may appear to be nothing more than semantics, I argue that this change in terminology is central to teaching what Emergency Medicine is about.

Once we’ve rid the residents of the idea of ruling out disease, we need to encourage them to think about risk stratification when they present the patient and incorporate that into their presentation. Residents are smart and once they get to know the faculty, they tailor the presentation and their proposed workup to what they think the faculty member will want to hear. We should encourage them, instead, to present the patient and tell us what they would do if they were in charge. This allows them to begin to feel the responsibility of their plans. Unfortunately, this takes time. After they give you their plan, you need to explain why you would do things differently. Why is your plan more or less risky than that of the residents? Explaining this will allow them to develop their risk taking behavior.

The most important part of risk stratification and risk decisions is the patient. When I finish a patient encounter and am ready to discharge patients home, I always sit down and have a discussion about risks and the need for follow-up. These two things go hand in hand. Often, patients believe that discharge from the Emergency Department comes with a clean bill of health and a 5 year, 100,000 mile guarantee. This again reflects the disconnection between what we as physicians think and what patients perceive.

When discussing disposition with the patient, sit down and turn off the phone.

When discussing disposition with the patient, sit down and turn off the phone.

How do we teach residents to communicate risk to patients? First we should start with modeling the behavior. Have the resident follow you while you have this discussion with the patient. Here are some simple things to do to maximize this interaction and model the proper behavior:

  • Sit down and turn off the pager/phone (no interruptions)
  • Explain everything that’s happened during the ED stay
  • Explain the findings (or lack there of) from your evaluation
  • Discuss your evaluation of all of the information and the presence of clinical uncertainty and the importance of prompt follow up
  • Discuss how the follow up will be arranged (patient calls or you are calling for the appointment)

Ask if the patient has any questions

I also like to add, “I’m okay with being wrong but I want you to give me the opportunity to make it right. Come back and see me or one of my colleagues if anything concerns you.”

There is no act of teaching that benefits the resident more than watching the proper behavior modeled. For the next patient, you flip the scenario and have the resident lead the discussion and you watch them. Afterwards, you offer them critique and tips to improve.

"No I've never sent home a patient to die but that's because I'm a good doctor."

“No I’ve never sent home a patient to die but that’s because I’m a good doctor.”

Finally, I think there’s an important role in discussing difficult cases where your risk stratification was incorrect. I’m not talking about during formal department Morbidity and Mortality conference but rather conversations in the clinical environment about these cases. This act stresses the importance of following patients up in order to evaluate the appropriateness of your level of risk taking behavior. Residents should understand that our understanding and practice of medicine is not perfect and mistakes will be made. The vital thing is to learn from these mistakes and adapt our clinical care and risk taking behavior accordingly.

Risk stratification and risk taking behavior are central aspects of Emergency Medicine. It is our job as resident educators to help residents develop these skills and attitudes. Since I’m by no means an expert in this area, I encourage you to email me, post comments etc on the topic so we can all learn more.

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The Importance of GRIT

“Grit or grittiness is a concept in education that emerged about 5-10 years ago, created by an academic research group led by Dr. Angela Duckworth.  Check out Angela’s TED talk here: Angela Duckworth. Duckworth’s targeted research audience tends to be primary and secondary education, however I think this definitely applies to medical school, residency, and other types of high level education.

Definition. Grit is not only a measure of an individuals ability to overcome adversity or failure (resilience) but also includes a person’s commitment to their passions/interests over the long-term.  People with grit not only work hard to succeed in whatever they do, but also have an ability to remain focused and committed to mastering a specific task or skill set. It is one of the many non-cognitive skills that educators once thought were inherent to the student, and left out of  curricula & formal education.  We now know it is possible to teach these “intangible” skills.

How to measure grit. The Duckworth group has created a 12-point scale that has been used to predict success.  I challenge each of you to take this 12 question test to see how “gritty” you actually are!

In a number of studies, they have found that grit is a better predictor of success than IQ, standardized tests, or any other type of exam we traditionally use to rate students.

Failure is a good thing.  Interestingly, I’m sure we’ve all heard the phrase - “I’d take a B+ overachiever over an A-student any day!” The concept of grit may come into play here – Duckworth believes that in some cases, talent and grit can be inversely related. Why? well, failure builds grit.  Failure provides the learner an opportunity to regroup, restrategize, and find an alternative path of success.  Those who are very talented may rarely experience failure, and as a result - not have the same drive to try over and over again until they eventually succeed.

Carol Dweck is a leader in the concept of the “growth mindset” which is also commonly found in those with grit.


Fixed vs Growth Mindset


Grit matters in medicine. Grit is a critical non-cognitive skill for physicians, especially those in emergency medicine, critical care, and other high-stress specialties. Resuscitations, and even careers for that matter, don’t always go according to plan – but we need to teach our students how to learn from their failures so they succeed and adapt the next time they are faced with a similar challenge.  It’s the teacher’s responsibility to foster and encourage grit.  You are teaching a skill that will help shape a lifelong career.

So, is it possible to teach grit?  Some wonderful suggestions on how to teach grit can be found below:

True Grit: The Best Measure of Success and How to Teach It

Stay tuned as we go through GRIT in more detail over the next few posts.  We are going to break down the 2013 White Paper on Grit - Promoting Grit, Tenacity, and Perseverance: Critical Factors for Success in the 21st Century and try to apply it to some critical issues in both medical education & training.


Suggested Reading

  • Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: perseverance and passion for long-term goals. J Pers Soc Psychol. 2007;92(6):1087-101. [Full Text Link]
  • Duckworth Research Group
  •  Shechtman N, et al. Promoting Grit, Tenacity, and Perseverance: Critical Factors for Success in the 21st Century. US Department of Education. 2013. [Full Text Link]

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Adopting FOAM: When and How?

OLYMPUS DIGITAL CAMERAIn this post, Rob Cooney, the man, the myth, the legend, discusses FOAM and the adoption of FOAM into practice. Recently, the FOAM world was able to have a front row seat at a great debate between two titans as they went head-to-head over the issue of adopting a change in practice.


Part 1: SMACC Gold: What to Believe-When to Change

Part 1: SMACC Back-On Beliefs of Early Adopters and Straw Men

Part 3: SMACC Back-Back on What to Believe and When to Change   

While I enjoyed the debate and found myself nodding in agreement with each of the speakers, in the end, I was left feeling a little wanting. There was very little practical advice given on how to adopt a change. In fairness to the speakers, this is a high level construct, a 50,000 foot view of the issue, designed to inspire you and make you think. That being said, Scott Weingart did give a glimpse of the solution:

“You need to put in the time. You need to read. You need to understand how to critically appraise new evidence; how to integrate it into your existing belief structure; how to then test that based on bedside clinical experience; based on your understanding of physiology, based on the specifics of every individual patient.”

He is absolutely correct in his statement. My only concern is that his call for a rigorous method will scare away early adopters and push them back into the early majority. I’m pretty sure that wasn’t his intent, but just in case, I wanted to offer a more “boots on the ground” approach that I think many of us could use to determine when to implement a change in practice.

The methodology that I believe will allow everyday clinicians to adopt changes in their practice is called the Model for Improvement. This year, I have the good fortune of being an IHI/AIAMC fellow. This means that I am learning, living, and breathing quality improvement. The Institute for Healthcare Improvement is a remarkable organization with quite the track record for implementing positive changes in healthcare. The model they use? The Model for Improvement. So what does this model look like?


fig 1-model for improvement2


As you can see, the model is based on three critical questions followed by iterative cycles of testing and learning. Let’s break it down piece by piece.

“All improvement requires a change, but not all change is an improvement.”

As you can see from the above quote, if we want to get better at something we have to make a change. Unfortunately, we sometimes can change things for the worse. Choosing what to change can be difficult. This is why the fundamental questions are critical.

Question 1: What are we trying to accomplish?

The first question can be viewed as the “aim statement.” This question must be answered very specifically. With quality improvement work, we attempt to identify the system, a timeline, and goals.

For example, “Within the next 12 months, we will reduce the door to doctor time in the emergency department from an average of 45 minutes to an average of 20 minutes.”

For practitioners working on individual improvements, they can easily choose much more manageable chunks to work with. Consider the use of push-dose pressors. Perhaps you have had difficulty with post-intubation hypotension and you’re considering the addition of push-dose pressors. Your aim could simply be, “I want to reduce the incidence of post intubation hypotension to less than 10%.” The key is to be as specific as possible. As they say at the IHI:

“Hope is not a plan, some is not a number, soon is not a time.”

Question 2: How we know that a change is an improvement?

 “In God we trust. All others bring data.”

                                                                                                            -W.E. Deming

This may seem obvious, but in order to determine if a change is an improvement, we have to measure something! In the above example of push-dose pressers, you would have to measure your rate of post-intubation hypotension. If the addition of push-does pressers did little to decrease your rate of hypotension, you’d likely abandon the practice before fully implementing it. While this seems intuitive, the actual measurement process can be made more robust by considering three types of measures:

Outcome Measures: These measures look at the performance of the system under study and are derived from the aim, i.e. rate of hypotension after intubation

Process measures: These measures look at the rate of utilization of an activity, i.e. use of meds, fluids, before and after vital signs

Balancing measures: Trying to improve one system at the expense of another should be mitigated as much as possible. Balancing measures attempt to look at the performance of the overall system. For example, how long does it take to intubate a patient with the addition of new drugs? Is there more hypoxia after the change?

It is also important to note that there are three kinds of measurement: research, judgment/accountability, or improvement. In terms of improvement data, we are not looking for rigorous, randomized, double-blind, placebo-controlled level data. We simply want “just enough” data to determine whether the change we are implementing is leading to an improvement.

Question 3: What changes can we make that will result in improvement?

This question is where improvement gets kind of fun. Depending on the complexity of the system that you are trying to improve, you may be able to come up with very simple ideas and test them easily. Answering this question also allows you to be quite creative in the solutions you suggest. Have you seen something work another industry that you think may apply to your day-to-day practice? Try it out!

Once you’ve answered the three questions above, it’s time to test the actual changes. These are done through iterative cycles known as “PDSA or Plan-Do-Study-Act Cycles.”


figure 2-use of pdsa1

These are simple experiments that take the ideas that you’ve created above and actually test them.

Plan: What are planning to do? How will you do it? Is anyone else going to test the change with you? how will you collect the data?

Do: Implement the test and collect the data

Study: What did you learn? Did the data match the predictions?

Act: What you need to change before the next cycle? Did it work well enough that you can apply it more broadly?

Notice from the above figure that the cycles are designed to be iterative, meaning one cycle flows smoothly into the next cycle as the data guides the improvements. Too often in healthcare, we identify a change and go straight into implementation. This is the dangerous practice that both Scott and Simon cautioned against. The below figure illustrates why it is important to implement changes very slowly. Every change comes with a cost. The higher the cost, the smaller the test should be. If there is a potential of harming a patient, VERY small tests are the first choice. This helps to mitigate the harm while allowing for future cycles to scale up if the change seems feasible. It also allows the early adopters to get things right before pushing the change out into the workforce.

new fig 3

While this model may seem complex, with a little bit of trial and error, it is quite simple to apply. It is also universally scalable. Want to lose weight? Apply the model: What am I trying to do? Lose weight. How will I know the change and improvement? My weight will drop, my clothing will fit easier, I’ll feel better, etc. What changes can I make? Eat less, exercise more, etc. These three critical questions, once answered, can then be tested, measured, and modified. Whether trying out simple new things were attempting to modify complex systems, use of this model allows a practical approach to making changes that drive improvement. It also allows “less expert” early adopters to safely dip their feet into the world of FOAM.

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Teaching Deadly Disease Detection

This is a different type of topic for iTeachEM…one we really haven’t covered before. What is the best way to teach trainees how to diagnose a relatively uncommon but deadly disease? Take, for example, acute thoracic aortic dissection….a very deadly disease, one we talk about all of the time when evaluating chest pain patients, but one we don’t encounter nearly as much as other chest pain entities like acute coronary syndrome and pulmonary embolism. How would you approach teaching folks about this uncommon disease? What pearls would you deliver that encapsulate how to prevent misdiagnosing or failing to diagnose aortic dissection (or any other rare, deadly disease) while at the same time not over ordering diagnostic tests? How does one teach this without making learners paranoid about each and every chest pain patient? This, of course, is part of an even bigger problem in EM/CC. How do you balance the desire and duty to detect uncommon, deadly disease with sensible test ordering? How do you strike a balance?

Rupturing aorta dissection

http://gallery.ctsnet.org/index.php/Adult-Cardiac/Diseases-of-the-Aorta/Miscellaneous-Aorta/Rupturing-aorta-dissection. Arnau Blasco Lucas

We are interested in your thoughts on this. Please comment here on the iTeachEM site and get the discussion started on Twitter.

How do you teach trainees how to pick up a relatively uncommon but lethal disease? How do you teach how to diagnose without driving expensive, wasteful workups? What are your tips and tricks for teaching junior learners the “right way” when it comes to taking care of patients with potential deadly disease?

The world of emergency medicine and critical care wants to know your opinion?

The following is a talk I gave at the SMACC Gold conference earlier this year. In this talk I discussed some pearls and pitfalls regarding this disease and how to increase your “pick up rate.”

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The Teaching Course is Coming!

Looking to infuse passion into your career as an educator? Not satisfied with the existing courses on medical education and teaching? Well, I give you….

The Teaching Course

What is the Teaching Course?

The Teaching Course is the premier experience in medical education and teaching. It’s a finely tuned blend of education, social media, and faculty development. If you can only choose one course in medical education to ignite (or re-ignite) passion in your career, this is it. This course aims to truly make a difference. And remember the course tagline: “Better Educators, Better Patient Care.”

The course is a week long experience of TED-like talks and workshops integrated with social media and FOAM (Free Open Access Medical Education). This is not your ordinary course filled with boring 60 minute Power Point lectures.

Please remember that this course is not just for emergency physicians. It’s for anyone who wants to make their mark on the world of medical education and social media. We have had pharmacists, nurses, and physician assistants take the course. If you want to be happier in your job as an educator and you would like to think that what you do on a daily basis makes a difference, then this is the course for you!

The Teaching Institute proudly presents The Teaching Course from Rob Rogers on Vimeo.

Why is this course special?

photo (11)

The Teaching Course Faculty

The course is special because we have captured the essence of why people attend conferences in the first place..to return home feeling refreshed, enthusiastic, and ready to change the world. It’s the same feeling I had after attending the SMACC Gold conference earlier this year. It is going to be an awesome course that will change how you view medical education and how you teach.

Who believes in us?

Several international societies and blogs/podcasts have already endorsed the Teaching Course because they believe in the phenomenal educational product we deliver.


What faculty are teaching in the course?

The faculty makes this course. Besides the usual University of Maryland suspects (Rob Rogers, Amal Mattu, Haney Mallemat, Mike Bond, et. al.), we have quite an impressive line up of guest speakers for the course. Just imagine a medical education & social media course with the likes of Victoria Brazil, Joe Lex, and Anand Swaminathan…UNBELIEVABLE!!  And this year we have a new Social Media Liaison, Anand Swaminathan (Swami). Folks, it is going to be amazing.


Victoria Brazil


Joe Lex

Swaminathan Headshot 2013

The Infamous “Swami”

How is this course different from others?

The Teaching Course is different from the “usual customers” in medical education/teaching conferences in many respects. We have broken the traditional mold and have developed a truly unique blend of short, TED-like talks and workshops. And don’t forget the social media and FOAM. Mix all of these together and you have a recipe for a course that can change the world of medical education.

Here is a short list of some of the things we do to set ourselves apart:

  • Livestreamed content (video-FOAM)
  • Livestreamed panel discussions (with live questions moderated from Twitter)
  • Heavy integration of social media and FOAM
  • Well known, motivational, dynamic speakers
  • “Flip the Classroom” packet delivered to all paid registrants prior to the course
  • Organized social events throughout the week
  • Emphasis on medical education, social media, and FOAM that will actually make a difference in your work setting.
  • The Legacy Program-if you pay for and attend a course you can come back to any future course (for FREE) and teach in it!
  • Unique workshops like the “Twitter Lounge” and the “Podcast Lounge.”
  • Group dinners including a very nice graduation dinner on the 4th night of the course
  • Tons of networking opportunities
  • Hands-on social media, FOAM, and medical education labs
  • Live Tweetwall
  • The PKTeach Talk Contest (deadline Aug 31st)

And that is just a short list. I don’t have room to include everything.

What’s new for 2014?

Lost coming this year. Lots of cool stuff. We will continue to Livestream some of our course content for free, and then we will release select presentations throughout the year. We just started our Legacy Program, so remember if you attend you become part of the Teaching Course family. You can come back to any future course for free. We will also find a way for you to teach some in the course.

We also have a new contest for this year (short notice): The PKTeach Contest. Just develop a PK talk on what your plans are to change the world of medical education and send to us. A winner will be chosen, and that lucky person will win FREE tuition to the course!

PKTeach Contest

What guest speakers do we have lined up for 2015?

We can’t release that one yet. Let’s just say it’s going to be huge. HUGE!

For more information about the course check out our website: The Teaching Course

Remember the dates for this year: Oct 20-24. We still have some spots open, so get on it and make your booking!

Hope to see you in Baltimore, Maryland in October!


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Is Live Conference Tweeting a Good Thing?

Is Live Conference Tweeting a Good Thing? Welcome to the Twitter-at-a-conference debate…

IMG_0547What do you think about live conference tweeting? is it a good thing or a bad thing? Is it useful or useless? Overdone or should be done more? For this post we have Swami and Jesse going head to head to debate the topic. Please post your comments and get the discussion started.

Ladies and Gentlemen….I give you….Swami and Jesse….



Swaminathan Headshot 2013

9:01 AM – I’m late for the start of the talk so I grab a seat in the back row, pull my laptop out and try to log on to the  conference WiFi. The signal is strong but I can’t reload my Twitter. Typical of these conferences, the bandwidth is  terrible. Alright, switching to plan B. Flip my phone into hotspot mode and link up.

9:03 AM – I can see the link on my WiFi drop down but still not picking up. Wait, there’s the signal. Okay. Reload  Twitter. Oh, I’ve got some notifications!

9:10 AM – Alright, let’s get into the talk and get some pearls out on Twitter. Wait, did he say arthrocentesis? I thought  this was the palliative care talk. Damn, I’m supposed to be in the room two doors down.

9:15 AM – Let’s grab a seat in the back and hope I can find a signal . . .

If any of the above sounds familiar, consider yourself part of the Twitter-at-a-conference debate. This post is the con side of the discussion with Jesse Spurr (@inject_orange) giving the pro side. I find it to be an unenviable, and hypocritical, position to take based on my Twitter history. However, I think there are some major points that need to be considered. As I thought about the post, I came up with three points I think are worth discussing:

  1. Tweeting detracts from your conference experience
  2. Tweeting can blur the message of the speaker
  3. Tweeting is a poor surrogate for actually attending the talk

Point #1 – Tweeting detracts from your conference experience

I’ve spent the first 5 minutes of many lectures getting my laptop set up and trying to find a WiFi signal (in fact the above scenario is modified from day #2 at SAEM in Dallas this year). 5 minutes doesn’t seem like a lot of time, but often the highest yield points are in the intro. Additionally, that first 5 minutes sets up the rest of the talk so losing focus here can make it tough to see the lecturer’s point of view and where they’re going. A lot of conferences are moving to shorter talks as well so you can actually miss the majority of the talk during set up.

Since it’s limited to 140 characters, it would seem that sending a tweet about some point from a talk wouldn’t take very long. But it’s not always easy to get across a point with those limitations and often, tweets take a bit of rewriting to get it right. This means you may miss the next point or, perhaps more importantly, you miss the statement that clarifies the point you tweeted out.

A tweet you send out can also lead down a rabbit hole that drags you into a discussion/debate instead of paying attention to the talk you are in. Here’s a tweet I sent from a talk at SAEM on the Critically Ill Obese Patient:

Swami tweet

This tweet set off some nice discussion on dosing meds and we drew in some experts (Bryan Hayes – @PharmERToxGuy) but the danger here is to delve into the discussion while trying to take in the talk.

Here’s another example of a tweet that can easily take more time than you intended:

Swami obese

Without the image, the tweet carries little information but with the image, you take away a lot on the importance of ramping. However, in order to construct the tweet, you have to find the image and insert it. More time lost while the lecture moves on.

All of this is to say that you can easily get distracted from the content of the talk. Many would argue that tweeting is a way to incorporate the information you’re hearing. While there may be some truth to this, we must remember that multitasking is a myth and so creating tweets is likely to distract our minds from the information at hand.

Point #2 – Tweeting can blur the message of the speaker

Anyone who has given a talk (either locally, at a national conference, or even an international conference) knows the amount of time that goes into creating a quality lecture. Joe Lex estimates that a 1-hour talk takes 40 hours to produce. It’s clear that the speaker has invested a great deal of time into this process and has worked very hard to craft a distinct message.

Then along comes the tweeting attendee who attempts to paraphrase 40 hours of work into 5-6 140-character tweets. It’s no surprise that the speaker’s message is often lost, corrupted, misinterpreted etc. These errant tweets can often lead to more side conversations and clarification from the tweeter leading to more wasted time. While I think followers can learn from tweets, the quality of the education may not be nearly as powerful as one would hope.

Some of this also hinges on whether it’s fair to send these messages out without the speaker contributing. If the tweet contains an error it is often attributed as an error of the speaker and not of the tweeter.

All of this leads into point #3 . . .

Point #3 – Tweeting is a poor surrogate for actually attending the talk

I think this is fairly self-explanatory but a critical point nonetheless. As Social Media and FOAM explode many are attending conferences virtually. There’s a real benefit to this since there’s no way to get to all of these conferences but trying to get all of the benefit of a conference this way clearly doesn’t work.

Aside from being able to choose which talks you want to see and getting all the points (not just the sexy ones that get tweeted out) you lose the passion of the speaker for the topic which goes a long way to raising your own interest level. There are also the above issues with the message being misinterpreted or corrupted. Additionally, you lose the conversation with peers that occur naturally at conferences. Finally, when following remotely, you often lose the tweets you want to see among the bevy of tweets being sent.

And so this simply becomes a matter of where is your time best spent? Should I spend an hour catching up on tweets from SMACC Gold or should that hour be spent reading (blogs, journal articles etc.)? As with everything in medicine, this is a cost-benefit analysis.

So, should we be tweeting from conferences at all?

As I stated previously, it would be hypocritical of me to answer this question with a no. I believe there is role for tweeting during conferences but perhaps a more organized approach is needed.

  • Adding individual hashtags to conference tracks (or even individual sessions) would be helpful for those following along at home.
  • A twitter moderator on site to clarify tweets and to field tweeted questions from the live and home audience.
  • Lecturers sending their own live tweets – see the prior post on iTeachEM from John Greenwood on how to do this with Keynote Tweet v2.5.
  • Post-lecture Twitter (or Google +) hangout with the speaker to field questions

And now for the pro side of things…



Live Tweeting from Conferences

IMG_2700 In the affirmative corner, arguing for free dissemination of knowledge (hmmm sounds a bit like that FOAM concept I’ve  read about on the interweb), @inject_orange, the nurse from Australia. For this debate I am using my Twitter handle, as  after all, that is really all that matters. Detractors of live tweeting will have you think I am a frustrated wannabe doctor,  a disgruntled nobody, wishing my name was up in lights as keynote speaker. So what if I view the Symplur Healthcare  Hashtag stats as a leaderboard that I am striving to win? Isn’t this just a motivator to spread a wealth of pearls to my  loyal minions… um… followers… uh, I mean colleagues. This topic is obviously one that lends itself to a degree of  skepticism and I am the first to admit that, from time-to-time, over zealous distributors of the words of others set me to  hover a cursor over the ‘unfollow’. With the caveats applied and no doubt to be addressed in the negative site of this debate, I genuinely believe that the live event Tweet offers much to the event, the audience, and the individual Tweeter (beyond fame and the honor of the Symplur Hashtag arms-race).

The Event 

While acknowledging the limitations of ‘Impressions’ as a metric for quality or true distribution, they are a valuable tool to chart the potential audience for content delivered in a face-to-face academic meeting. When applying a research methodology to this process a relatively sophisticated phenomenological examination of the social educational structures and interactions of the audience is possible (see EMJ publication by Neill et al. 2013). To translate this to something applicable and not simply a marketing and demographic tool, consider evaluation of learning. The Kirkpatrick Model of Evaluation is arguably one of the most broadly accepted model of evaluation of learning outcomes from an education intervention. Most conferences, symposiums and meetings are only really able to demonstrate evaluation to a Level One standard.

The Kirkpatrick Model

Level 1: Reaction

To what degree participants react favorably to the training

Level 2: Learning

To what degree participants acquire the intended knowledge, skills, attitudes, confidence and commitment based on their participation in a training event

Level 3: Behavior

To what degree participants apply what they learned during training when they are back on the job

Level 4: Results

To what degree targeted outcomes occur as a result of the training event and subsequent reinforcement

The significant difference as an educator evaluating an event full of Tweeters (in comparison to the more traditional Likert scale based ‘happy sheet’), is the capacity for huge volumes of Level 2 evaluation data. Live Tweets are snippets of information that have been presented by a speaker, decoded by the audience, encoded in the context of meaning to the learner and re-presented as demonstrable piece of knowledge gained in this conference session. It would even be a reasonable assertion that with subsequent follow up Tweets on return to workplace such as:

“Used the NODESAT Ap Ox during RSI today, thanks @airwaycam #smaccGOLD” (fabricated for purpose of article – conglomerate of many post SMACC tweets)

We are able to begin to see Level 3 standards of evaluation. This level is very difficult to capture as an outcome from most structured large group educational endeavors.

The Audience

Large volume live Tweeting changes the dynamics of a conference audience. It brings previously passive delegates into the discussion in real-time, allows for live peer-review, sharing of links that augment the speaker’s presentation and navigation to like-minded colleagues that may otherwise sit on the other side of an auditorium with no commonality other than co-location.

The Individual

When used well, the live Tweet also allows the participant to decode, process and reflect on the content and reshape into an often paraphrased on consolidated point like a live reflective journal. Another common theme cited by proponents of the live Tweet, is the flattening of hierarchy and the confidence to voice an opinion. I can completely empathize with this view.

In terms of the less altruistic motives, such as increased profile and leader board monitoring, I believe that the motive does not degrade the outcome. If someone is willing to do something that clearly takes a degree of skill and logistics (have you seen how fast a smartphone battery dies when Tweeting?) and contributes to my learning as a fellow follower of FOAM, they deserve every bit of ego massage they get from taking out the Number 1 Influencer spot.

To wrap up, I would like to issue a personal thanks to Matt and Joe for contributing to my learning via Twitter from ICEM 2014 in Hong Kong. I was not there, but I learned several pearls via the number one and two Twitter Influencers of #ICEM2014 and was thankful for the great gift this conference gave me in evidence of how truly awesome live Tweeting can be (bad timing to be writing a negative argument hey Swami?). The profile of these two Tweeters further supports the assertion that selfish motives are rarely the driver of good live Tweeting (Matt = TV Star and Joe = EM and Medical Education Pioneer) – they didn’t need the fame.

Some Further Reading

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