Advanced training in emergency medicine: a pedagogical journey from didactic teachers to virtual problems.
ABSTRACT As trainee numbers and the geographical spread of training departments have increased, the model of weekly face-to-face teaching has come under strain because of long travel times. This has been compounded by a reduction in the total number of hours worked by trainees. Furthermore the traditional teacher centred educational programme has been challenged as unfit for purpose on grounds of both content and style.
This article describes two shifts in the delivery of the programme. The first involved migration from a didactic delivery to a problem-based model; the second a gradual shift to the internet culminating in implementation of a web based virtual learning environment.
The principles outlined in this paper are widely applicable and will be of interest to all clinical educators within the specialty, both within the UK and overseas.
- SourceAvailable from: ncbi.nlm.nih.gov[show abstract] [hide abstract]
ABSTRACT: Emergency medicine is a relatively new specialty area within medicine, however medical schools, students and standard setting bodies have recognised that learning emergency medicine is integral to the training of medical students. There are, however, significant problems with the delivery of emergency medicine teaching including low teacher numbers, severely limited teaching time and lack of suitable learning resources. This paper describes the process of development of a learning resource, its format and content and summarises student feedback.Journal of accident & emergency medicine 10/2000; 17(5):320-3.
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ABSTRACT: Interest in conducting problem-based learning (PBL) on-line has increased to meet student and physician schedules. Little research describes skills needed to facilitate PBL on-line. In this paper we studied teaching presence in asynchronous PBL groups. Two raters, with average inter-rater agreements of 0.80, used an existing code to measure teaching presence in 62 PBL case discussions facilitated by one instructor over five years. This instructor was selected because of consistently high teaching evaluations. Messages sent by the instructor in the on-line PBL discussion were coded into three categories: instructional design and organization, facilitating discourse and direct instruction. Instructional design indicators were most frequent averaging 22.5 (SD = 5.6)/discussion. Facilitating discourse and direct instruction were comparable, 19.5(SD = 7.4) and 19.5 (SD = 6.7), respectively. Messages and indicators of teacher presence rose across time with a decline during subsequent PBL cases with the same group.Medical Teacher 09/2006; 28(5):425-8. · 1.82 Impact Factor
Article: E is for everything-e-learning?Medical Teacher 10/2001; 23(5):441-444. · 1.82 Impact Factor
Advanced training in emergency medicine: a pedagogical
journey from didactic teachers to virtual problems
Kevin Mackway-Jones, Simon Carley, Darren Kilroy, on behalf of the St Emlyn’s Development Team
............................................................... ............................................................... .....
See end of article for
Professor Kevin Mackway-
Royal Infirmary, Oxford
Road, Manchester, M13
9WL, UK; kevin.mackway-
Accepted 26 June 2007
Emerg Med J 2007;24:696–698. doi: 10.1136/emj.2006.043885
Background: As trainee numbers and the geographical spread of training departments have increased, the
model of weekly face-to-face teaching has come under strain because of long travel times. This has been
compounded by a reduction in the total number of hours worked by trainees. Furthermore the traditional
teacher centred educational programme has been challenged as unfit for purpose on grounds of both content
Objective: This article describes two shifts in the delivery of the programme. The first involved migration from
a didactic delivery to a problem-based model; the second a gradual shift to the internet culminating in
implementation of a web based virtual learning environment.
Conclusion: The principles outlined in this paper are widely applicable and will be of interest to all clinical
educators within the specialty, both within the UK and overseas.
teaching has occurred and been effective. This is challenging in
any setting, but particularly in specialties like emergency
medicine in the UK where regional cohorts of specialty higher
trainees work shift patterns and are dispersed to hospitals over
a wide geographical area.
The North West emergency medicine specialty training
programme (Specialty Training in Emergency Medicine—
STEM) has been preparing trainees to pass the specialty exit
exam since the onset of specialist registrar training and was
initially very successful. However, in recent years, with
increased trainee numbers and consequent greater geographical
spread, the model of weekly face-to-face teaching sessions has
come under strain because of long travel times. This has been
compounded both by a reduction in the total number of hours
worked by trainees and also by the need to ensure that shift
rotas comply with the requirements of the European Working
Time Directive (EWTD). Furthermore the traditional teacher
centred educational programme was challenged as unfit for
purpose by the trainees who felt that both content and style
From an educational perspective we have also seen a shift
away from behaviourist models of learning towards social and
constructivist learning pedagogies. However, the geographical
and chronological dispersal of trainees has often meant that it
is difficult to develop learning networks to support such a
change. Indeed, it could be argued that changes to working
practice have suggested a need for independent and individual
expounded the adoption of a more constructive and collabora-
tive approach that requires intellectual and social interaction
between learners. From a pedagogical perspective we are
advocates of a blended approach to learning, picking the right
pedagogy for the task required. However, in practice, the reality
of emergency medicine practice—that of discussion, constant
development, rapidly shifting knowledge base together with a
high degree of necessary interpersonal discussion and debate—
means that we have developed as social and constructivist
tutors.1This means that we place great emphasis in assisting
individual and groups of learners to educate themselves and
here is increasing emphasis on the need to quality assure
medical teaching both by delivering content defined by
national curricula and also by providing evidence that this
others and to allow them to develop their own thoughts and
solutions. Online learning offers a variety of approaches,2but
we believe that group interaction and social learning are
essential for effective emergency physician education and
This article describes two shifts in the delivery of the
programme: the first involved migration from a didactic
delivery to a problem based model; the second a gradual shift
to the internet culminating in implementation of a web based
virtual learning environment (VLE).
WHY PROBLEM BASED LEARNING?
Problem based learning (PBL) supports the key elements of
adult learning. PBL has been extensively debated elsewhere.3–5
The seven step Maastricht method of PBL used in Manchester6
requires the same group to open and close a case. This allows
the learners to both identify problems and then answer them as
PBL is widely employed in UK medical schools and has
attracted increasing interest at postgraduate level as it allows a
senior group of clinicians (the trainees themselves) to take
control of the specific educational content of each session while
the course designers retain overall control by specifying the
content of the cases for discussion. This promotes professional
team working within the groups and allows them to focus and
develop their own ideas and solutions.
DESIGNING AND DELIVERING A PBL COURSE
Initial core content for the North West PBL programme was
developed around a series of meetings between trainees and
trainers that took place before the publication of the original
FFAEM curriculum. Content was generated and refined with
the aim of creating a succinct series of learning modules which
best reflected common and/or important clinical scenarios and
problems in everyday practice.
These discussions resulted in the design of six distinct clinical
modules as shown below:
Abbreviations: EWTD, European Working Time Directive; FCEM,
Fellowship of the College of Emergency Medicine; FFAEM, Fellowship of
the Faculty of Accident and Emergency Medicine; PBL, problem based
learning; STEM, Specialty Training in Emergency Medicine; VLE, virtual
N Advanced management of acute medical emergencies 1
N Advanced management of paediatric emergencies
N Advanced management of trauma emergencies
N Advanced management of surgical emergencies
N Advanced management of acute medical emergencies 2
N Advanced management of psychosocial emergencies.
With the publication of the FFAEM (now FCEM) curricu-
lum,7content was reviewed to establish mapping to national
learning requirements and to benchmark STEM’s quality
The six 12-session modules run over a 3 year cycle. Each
session contains one or two cases for discussion. The cases are
designed to guide students to consider both clinical and
managerial aspects of emergency medicine practice in accor-
dance with good PBL case design.8
Based upon the geographical spread of the region, three
subregional learning groups were established, each following
an identical programme track such that trainees from across
the North West are each at the same stage in the STEM cycle.
These groups meet biweekly throughout the year and each PBL
session lasts 2 h.
WHY MOVE TO THE WEB?
Initially cases were written and distributed on paper. Soon the
distribution was by email, but the fundamental method of
sending cases to each of the trainers and trainees was
unchanged. As could be expected, significant numbers of
participants forgot their papers or left significant parts behind,
and this could detract from the delivery of the sessions. It was
realised that a website would allow equity of access throughout
the region and would also allow the inclusion of higher
definition supporting materials such as x rays, videos and
sound files. The website (www.stemlyns.org.uk) was funded
through the National Health Service Modernisation Agency and
is still, to our knowledge, the only hospital built with
government money, on time and within budget.
Despite the improvement in access that resulted from a move
to the web-based case repository, the trainees’ work patterns
continued to be a barrier to universally effective PBL, or indeed
any learning modality that demands physical presence for all.
Such problems are not limited to emergency medicine. The
majority of the analysis, classification and formulation steps in
the Maastricht model take place in face to face sessions.
Members of the group unable to attend face to face sessions
were therefore unable to fully take part. In effect this meant
that only a minority of trainees were able to participate and
therefore benefit from the discussions in a face to face manner.
In an attempt to facilitate fuller trainee interactivity and
remove the barriers inherent in the original St Emlyn’s model,
we migrated the PBL course into an open source course
management system, Moodle, in 2006. VLE systems such as
Moodle offer a wide range of information and activity types.
The requirements to facilitate PBL are limited and easy to set
up, and comprise the tools needed to facilitate asynchronous
communication, content delivery, internal and external web
links and feedback modules. This is shown in fig 1.
to attend a face to face meeting. Learning outcomes can be
developed in the meetings or online, and reporting can be
delivered via thediscussion boardsto allow all members to benefit
from the work of the group. This allows even those who were not
present to take part. Passive learners can observe the construction
and dialogue and still gain and learn from the case based
solutions to the problems posed bythe PBL group.In addition, the
course tutors can see the activity of the group, take part in the
discussion as a co-learner, and facilitate if required. The tacit
educational benefits for VLE tutors are significant in themselves.
Our current model has sub-regionally based trainee groups
who meet both face-to-face and virtually. A tutor is still
allocated to facilitate each of the face to face sessions but there
is relatively little interaction between tutors and trainees on-
line. The variability of a need for virtual tutor interaction on a
day by day basis arguably reflects the seniority of the trainees,
their inherent motivation for learning and their familiarity with
PBL teaching. Other online PBL courses aimed at students have
required a much greater tutor presence,9with a greater need of
facilitation than in traditional PBL, but we have not found this
to be necessary. While much of the e-PBL system is self
supporting, a team of two consultants oversee the virtual
environment for each module.
Screenshot of a PBL Moodle session on St Emlyn’s.
Advanced training in emergency medicine 697
The courses are currently aimed at specialist registrar training,
but will migrate without modification into ST 4–6 training
under Modernising Medical Careers in 2007.10The precise year
at which a trainee joins the programme is not materially
relevant since all trainees remain in the teaching groups for at
least 3 years and will therefore complete each module at some
point before the end of training.
VLEs are only one element of a comprehensive educational
approach and have well-recognised limitations.11Care must be
taken to address other aspects of education that cannot be
delivered via the web. For example, practical skills, history
taking, attitudes and interpersonal relationships are best taught
at the bedside with a skilled tutor.
We have recently augmented the established VLE package
with a series of competency-based skills which are learnt and
taught in small group format alongside the cognitive (knowl-
edge based) course elements.
Trainees acquire skills confidence based upon the established
‘‘four stage’’ approach to psychomotor learning. Subregional
meetings allow hands on practice based upon standardised
competency documents which are made available to trainees in
advance of each session. Within each session, a designated skill,
drawn from the skills bank, is chosen for practice.
The guides are in a downloadable format, are mapped to the
OSCE requirements of the FCEM diploma, and can therefore be
used as a written record and revision aid by trainees in
preparation for speciality examinations. It is vital to remember
that e-learning is simply an additional tool for emergency
medicine education, it cannot and should not entirely replace
Although the focus of the PBL courses is the education of the
trainees, the information sought, appraised and disseminated
online by them is just as valuable to the trainers. A further
advantage to the VLE facilitation is that this information can be
easily shared, and that all trainers can be made aware of the
core STEM training and the individual skills that are the core of
emergency medicine practice.
Our experience in developing and delivering a VLE PBL course
for senior trainees in emergency medicine strongly supports the
idea that VLE is a necessary core element of effective medical
education in the emergency department. Furthermore, the VLE
can be used as a focus for skills training in a blended12approach
to professional education.
If you want to know more then please contact us by email or
letter. You can also visit one of the links below where you will
be able to see demonstrations of the courses and learning.
N Moodle: http://www.moodle.org
N StEmlyns virtual hospital: http://www.stemlyns.org.uk
Most courses on the StEmlyns site require a password to
enter, but you can view the ‘‘Getting to know Moodle’’ course
and the demo course, which will illustrate key features of the
Kevin Mackway-Jones, Simon Carley, Emergency Department,
Manchester Royal Infirmary, Manchester, UK
Darren Kilroy, Emergency Department, Stepping Hill Hospital, Stockport,
Competing interest: None declared.
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Emergency Care Specialist Library
Please visit the Emergency Care Specialist Library www.library.nhs.uk/emergency via the EMJ
This is a valuable resource containing a library of guidelines, Cochrane reviews, systematic
reviews and management briefings relevant to emergency care.
698Mackway-Jones, Carley, Kilroy