Sunday, July 1, 2012

The Advancing Role of Technology in Emergency Medicine Education and Training; An Interview with Mel Herbert, MD FAAEM

Originally Published: Common Sense, July/August 2012
Original Author: Ali Farzad, MD

Mel Herbert, MD FAAEM
We are in an age of information explosion, overloaded by an expanding knowledge base that is accelerating at an unprecedented rate. It has been estimated that the world’s body of knowledge will double every 35 days by 2015. (1,2) Physicians in particular must be able to process this ongoing onslaught of newly discovered information throughout their careers. As new information arrives and replaces the old, the knowledge base of physicians must be supplemented with new training and opportunities for continued learning. Discovering how to obtain and sustain lifelong learning will be critically important to modern physicians.

There is also a new generation of learners. Students in today’s medical schools are primarily “digital natives,” in contrast to “digital immigrants, and traditionalists.” (1,3,4) Born into a digital world, these young “digital natives” speak the language of technology fluently, as a native tongue. Having grown up with easy access to Google, Wikipedia and digital textbooks/references, these learners use of and attitudes towards technology are dramatically different from those of their parents and teachers, the “digital settlers or immigrants.” These are people who learned to use technology after a formal education, before access to computers was available to them - not “born digital” but who now “live digital.” They now use digital technologies, but do so “with an accent,” typical of someone who has learned a new language as an adult. Lastly, the “traditionalists” grew up without technology and have not embraced it as a core part of their teaching. With most students and residents now being “digital natives,” they expect their education to reflect their level of technology integration. Medical schools and residency programs will have to shift their approach to teaching in this digital age, as these new learners will inevitably bring about change in the way their education is structured and delivered.

In this article, I will attempt to explore the advancing role of technology in emergency medicine (EM) education and training by picking the brain of one of our true leaders in EM education. Dr. Mel Herbert has kindly allowed me to ask him a few questions about how EM education and training can be improved through the proper implementation of technology. Dr. Herbert is host of Emergency Medicine: Reviews And Perspectives (EM:RAP), a monthly audio series for all things emergency medicine. Since 2001, EM:RAP has served as the perfect example of how technology can be effectively implemented to make learning easier and more effective. EM:RAP features some of the best speakers in EM who discuss and teach through an effective audio format. It is one of the fastest
growing audio publications in emergency medicine with over 8,000 subscribers, and it has recently implemented Web 2.0 technology in a new website that makes it easier to use and learn from than ever before.

AF: So Dr. Herbert, please tell us a little bit about yourself and your educational background. Where are you from? Where did you do your training? How did you choose to specialize in emergency medicine?
Dr. Herbert: I was born in Australia, and in the 1980s, I went from high school straight to medical school in Melbourne, Australia, at Monash Medical School. I took a year off, in 1987, to study abroad and do a bachelors of medical science at UCLA. I worked for NASA during that year, which sounds really cool, but basically it was just hanging rats by their tails. I loved America, and I had a great time here. I knew even then that I wanted to come back to do more training in the U.S. after finishing medical school. As it turned out, I ended up getting married to an American at the end of that year, went back to Australia, and finished medical school. I did a couple years of residency before returning to the states to do an emergency medicine residency. In choosing a specialty, I liked the emergency department the most because I could do my work and then go home; I liked the lifestyle. When I was a student, one of my senior residents told me, “You know I like EM because our patients come in really, really sick, we make them a little less sick, and then we send them upstairs.” I thought it was a humorous slant on it, but I liked the idea of being able to deal with everything. I was also very afraid as a student that people would eventually expect me to actually know something. I was afraid that I would witness someone choking during dinner or see someone’s kid get hit by a car and that if I was a dermatologist, I would not know what to do. That’s a part of EM that I love. It makes me feel like a real doctor. I also love the procedural aspects and generally just like the concept of providing emergency care. Of course, it is not without its problems, but it is just an absolutely wonderful field.

AF: What do you think about the role of technology in medical training? How about EM education and training, specifically? What are the areas of study that can be supported with technology in your opinion?
Dr. Herbert: I don’t think we have even scratched the surface of what we should to be doing. There are a number of different ways you can divide this up, but I’ll try and stick to the stuff that I know. Bill Gates is trying to do this; he has had this revelation, and I share the idea with him. Look, in EM we have close to 170 different residency programs, and in those programs, we are trying to teach residents how to do many different things, be it didactics, professionalism, procedures, etc. In terms of just the raw didactics information that we have to digest, there is a lot of redundancy and inefficiency. It seems crazy to me that a tiny little EM residency program in Mississippi is trying to create and present a didactic program from scratch, while giant programs in L.A. and New York try to do the same thing, yet all individually. Some programs have world experts  and the absolute best educators in some topics, but these educators are absolutely atrocious in other subjects and topics. This is true everywhere. For every single residency program to try and produce their own didactic program seems labor intensive and inefficient. Instead, what we should strive for is a unified resource consisting of the best speakers, the best lecturers and the best information about EM in one centralized location that is accessible to everyone, everywhere, at anytime. So, what I am really interested in with EM:RAP, Essentials and some of the other products we are working on, is assimilating the best and most interesting didactic program, available in easily digestible chunks, so then it can be disseminated to everybody. I think it is better for learners to go home and watch a video, interact with it, listen to some audio, then come to rounds or the classroom prepared for discussion and problem-solving sessions. A lot of learning occurs during discussion after the students have had a proper introduction to the basics of a topic, rather than spending a lot of hours just sitting there and passively listening to lecture that may or may not be useful. So I see the future of medical education being benefited by having a collection of the best speakers and best talks easily available to learners in a centralized location so students can learn in their own way, at their own pace, and then apply what they have learned practically in small group sessions at their respective residency programs. That’s when the real education will occur.

AF: How did EM:RAP start? What is the goal of the program? How has EM:RAP progressed throughout the past 10 years? What can we expect from the future of EM:RAP?
Dr. Herbert: EM:RAP started in 2001, and like all good programs, it came out of a complete failure. Before EM:RAP, I enjoyed listening to audio programs like audio digest to educate myself in my car
during my commute. Audio can be a very efficient form of learning, as you can usually multitask and learn while driving, running, etc. So I started a program before EM:RAP that was for nurse practitioners called Nurse Practitioner Informer. It went for about a year and a half and was well received, similar in nature to EM:RAP, but I did all of the content myself, and it just drove me insane. I was not smart enough at the time to realize that I did not have to do all the content myself and that finding others to help would actually make it a lot better. I stopped recording thinking “I can’t do this,” but I really believed in the audio format as a great way to learn and decided to later start EM:RAP with Rick Bukata.

Since the program was launched in 2001, it’s been a continued process of making changes and improvements. It used to be just really long lectures that were edited to add emphasis and summary. Over time, we started working with organizations like AAEM to broadcast big national lectures and decided to pay the speakers for their quality lectures, which is something that other people did not do. Recently, over the past few years, we moved away from just lectures to commentary by experts in their field who frequently do podcasts and are really professional, well known and well respected. The commentary is now interspersed in between the lectures, summaries and reviews. This helps bring important information from the foremost experts on a wide range of topics directly to the user. We just recently added in the past few months the C3 Board Review Project. It is a detailed, monthly summary of the things you need to know for boards, straight from textbooks but effectively reviewed in an audio format. What we want to do is get through the entire knowledge base of emergency medicine every three years, and then do it again and again, constantly improving the product. Ultimately, in the future we will be combining (short video clip summaries) with EM:RAP and thus linking the audio and video content. We also have written summaries to cover all aspects and allow the users to read, listen, look and learn the content in an easy manner that promotes retention of the information. In addition, we are sending audio updates with short tidbits that are sent through
email that emphasize what has been done as a review and also keep the reader up-to-date on the latest breaking information. The mobile platform is where most people will be consuming their information, and we created our new website with this in mind, which in its current form is spectacular, but it will be even better with many improvements to come.

AF: As an educator, how do you incorporate technology to make education and training more effective and efficient for your students and residents?
Dr. Herbert: We started this thing called EM Core Content at the residency about four years ago. We have these great lecturers come and talk, but at the end of five hours of much can you
really remember? For me, it was only two or three things. So I started recording our weekly conferences at USC. A lot of people record their grand rounds, but the key thing to make it work in my opinion is good audio quality. To get good quality audio you need good audio equipment, which gets very expensive, and it is not easy. I have been doing this for about 15 years, and there are still months when I listen and think, “Boy, it is still not quite right.” The goal should be to get the best audio quality possible. There is so much visual content that both the slides and speaker should be recorded. However, if you really want to make something interesting and enjoyable to watch, you need multiple cameras, so it looks like CNN. We, as instructors of emergency medicine and medical education in general need to raise the bar and use technology to create high quality professional audio and video that will captivate the audience.

Dr. Stuart Swadron and I do a lot of small group teaching, where we refer our students to listen to our educational materials like EKG videos at home before we discuss it in person. It gives people the opportunity to listen and learn at their own pace because people learn very differently, and some people have a lot of knowledge in one area and not so much in others. This method is much more powerful, as opposed to being in a big group where learners may avoid discussing what they do not understand. The educators who implement this most effectively are the language and learning people, like Rosetta Stone and others who have spectacular ways of learning new languages while incorporating this visual, written in creating a better learning experience using technology. People
learn at different speeds, and technology allows us to create a place where people can learn at their own pace, but it always comes back to having really good quality educators. The best person I’ve seen do this ... honestly, is Stuart Swadron. He is somebody who is able to take multiple sources of information that are very complex and summarize it down to useful tidbits. You can have all the audio and video equipment in the world and make it look slick, but in the end, success is always going to come from a master educator. Someone like a Stuart Swadron, a Billy Mallon, a Corey Slovis (and the names go on); someone who can take the information and synthesize it into chunks that make sense to someone in EM. So it always comes down to having the best educators, and then we use technology to present the information in the most effective way possible.

AF: As a clinician, how do you use technology to make your life easier? Any suggestions for must have software, apps or resources to help others do the same?
Dr. Herbert: I use my iPhone at work. Constantly. I use it to pull up information I need at the point of care in real time. But there are a few things that I think we don’t do well with that technology. Don’t forget the power of that phone. Here is one way I’ve been using it. If I have a consultant that I want to share information with, I take pictures of the physical exam finding in question, and I send it directly to my consultant. This speeds things up and allows me to more quickly disposition patients who are in need of specialty care.

Another use is to provide more useful discharge instructions. We write stuff on a piece of paper that people never read or lose. Well why not record your instructions on your phone and email it to
them directly? Now, people may freak out about the medico legal consequences of this, and yes, this will have to play out. But, we should not hold back on using technologies like this that will clearly improve the care we provide for our patients out of fear of litigation. Yes, you could get sued for not saying the exact right thing on your discharge instructions, but you can also get sued right now because you did not write everything down perfectly. So don’t be afraid of the lawyers; we should embrace this technology and use it to help and educate our patients. Just remember about the HIPPA laws, and make sure to get full consent from all your patients, but I think there is an enormous potential for us to help our patients by using this technology to educate them on the fly.

AF: I’m sure you have thought a lot about the future of EM and EM education. Are you optimistic about the direction the field is taking?
Dr. Herbert: I am extraordinarily optimistic about the direction the field is taking. I said it before, and I will say it again; I don’t think we have even begun to scratch the surface of what we can do. We at EM:RAP have been involved for quite some time and hope to be further involved. I think there has been an explosion in how we can use technology to advance education; however, the problem is that as it gets easier to share information, a lot of people are throwing things online, and frankly, much of it is not very good. So our goal is to not just share information but to seek the best available stuff out
there from the best speakers and give them incentive to continue to create great educational materials. The possibilities here are vast, and we have not even begun to go all the great things that are

In regards to what I wish I could change, the CME process is really broken. The process of distributing the CME for your program is complicated for many reasons. Some of the reasons are just and in place to make sure everything is appropriately disclosed to limit bias from 3rd party interests. Small operations that are looking to provide CME can have a difficult time and need extensive resources as it is very expensive. Many times the people who have the resources and cash (usually drug companies) may have conflicts of interests and will present information with bias for their own benefit. Hence, these people are allowed to present the “educational materials,” not necessarily because it is good information, but because they have lots of cash. This has been a concern of mine for several years - that a lot of the education physicians get for free is not focused on improving patient care, but rather, it is presented because these companies stand to benefit for disseminating biased information. As a learner, you must ask yourself, “Why am I getting this information for free?;” is it free because it is crap?, or is it free because some third party that somehow stands to benefit is paying for it? If there is a third party paying for it, then it is essentially marketing, and you
should stay away from it. It is difficult enough to figure out what the right thing to do is when you are getting your education from a nonbiased provider, but far more difficult if the person who is providing the information is also trying to sell you something other than just pure education. That’s my beef.

AF: You have clearly incorporated technology successfully to assist your teaching for many years now. What advice do you have for educators (digital immigrants or traditionalists) who would like start using technology to improve their teaching and practice?
Dr. Herbert: There is a wealth of technology that now makes it possible to create audio and video products. The most important part is taking the time to research, understand and synthesize the
material you want to present to make sure you have appropriately prepared to present it effectively. Don’t forget the first step, which is to make sure you understand the information well. To be effective, an educator must have done the hard work of synthesizing the material and preparing the information to come up with the best and most interesting way to teach it. If you skip that, the rest of the stuff does not matter; all the technology and audio/video equipment in the world will not make that information useful.

AF: What advice would you give to current residents (digital natives) who are looking to make their learning as effective and efficient as possible?
Dr. Herbert: There are enormous amounts of information and resources available. Talk to your peers and colleagues, particularly fellow residents, and ask where people are getting their information, and figure out what works best for you. Everyone learns their own way, and finding out what works best for you is step number one. Remember the basic psychology of learning - that most people have to hear things multiple times before it can be retained in long-term memory. I suggest a learning schedule that promotes lots of repetition and encourages constant review. Remember that this is a life long learning profession. Emergency medicine as a specialty consumes the most CME when compared to any other single group in medicine that I am aware of. I think this is because EM is very broad field, but more importantly, based on fear. We have a very scary and very broad field that simply requires us to constantly educate ourselves in effort to be prepared to take care of our patients. Find what works for you, and use it frequently. Find things that you find interesting, and prepare to be a life-long learner.

Editor’s Note: As a resident, the value of using technology to teach and make educational resources more accessible is clear. AAEM/RSA continues to support the education of our members, and in an effort to make your learning more efficient and effective we are proud to offer EM:RAP as a brand new free member benefit! We would appreciate your feedback on this article and your thoughts on the advancing role of technology in EM education. Please send comments and suggestions for future articles about technology and emergency medicine to

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2. Cornall R. Speech at Queensland University of Technology Faculty of Law Graduation Ceremony. < QUTFacultyofLawGraduationCeremony>. Accessed November 20, 2011.
3. Prensky M. Digital natives, digital immigrants. On the Horizon. 2001; 9:1–6.
4. Palfrey J, Gasser U. Born Digital. New York, NY: Basic Books; 2008.

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