Innovative strategies in critical care education - Journal of Critical Care

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Even strategies of accreditation are evolving. This review attempts to ... Half of what you will learn in medical school will be proven wrong in. 10 years. ..... computer sciences, MOOCS are offered in a wide variety of areas, includ- ing medicine ...
Journal of Critical Care 30 (2015) 550–556

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Clinical Potpourri

Innovative strategies in critical care education☆ Christopher R. Tainter, MD a,⁎, Nelson L. Wong, MD b, Edward A. Bittner, MD, PhD b a b

University of California, San Diego, San Diego, CA Massachusetts General Hospital, Boston, MA

a r t i c l e

i n f o

Keywords: Technology Education Medical education Critical care Intensive Care Innovation

a b s t r a c t The cadre of information pertinent to critical care medicine continues to expand at a tremendous pace, and we must adapt our strategies of medical education to keep up with the expansion. Differences in learners' characteristics can contribute to a mismatch with historical teaching strategies. Simulation is increasingly popular, but still far from universal. Emerging technology has the potential to improve our knowledge translation, but there is currently sparse literature describing these resources or their benefits and limitations. Directed strategies of assessment and feedback are often suboptimal. Even strategies of accreditation are evolving. This review attempts to summarize salient concepts, suggest resources, and highlight novel strategies to enhance practice and education in the challenging critical care environment. © 2015 Elsevier Inc. All rights reserved.

1. Introduction

Half of what you will learn in medical school will be proven wrong in 10 years. We just don't know which half. [C. Sidney Burwell (1893-1967)] The totality of medical knowledge continues to increase at a dramatic pace [1,2], and each generation of learners has a greater deal of material to master than any preceding generation. In response, learning styles continue to develop as well, and effective educators should adapt their teaching strategies to accommodate their learners. The educational efforts of medical educators must be balanced with a duty to their patients. Increasingly, these are whittled by additional obligations, like administrative responsibilities, publication requirements, and an increasing proportion of time spent with documentation and billing. Care and education in the intensive care unit are certainly no exceptions. If anything, the acuity of care necessitates even more accurate and efficient educational methods. It has been recognized that this is an area with continued potential for improvement [3]. This review will provide an overview of educational principles and how emerging technology can augment them. Supporting evidence is provided when available. Critical care encompasses elements from all specialties; thus, many of the principles discussed are generalizable to medical education as a whole. Rather than providing a blueprint, the

☆ No financial support was provided for this manuscript, and the authors have no conflicts of interest to disclose. ⁎ Corresponding author at: University of California, San Diego, 200 West Arbor Dr, San Diego, CA 92109. Tel.: +1 206 356 3853. E-mail addresses: [email protected] (C.R. Tainter), [email protected] (N.L. Wong), [email protected] (E.A. Bittner). http://dx.doi.org/10.1016/j.jcrc.2015.02.001 0883-9441/© 2015 Elsevier Inc. All rights reserved.

intention is to provide a framework, from which educators can understand and improve their curricula and teaching strategies. 2. Adult learning (andragogy)

Education is not the learning of facts, but the training of the mind to think. [Albert Einstein (1879-1955)] The physician historically operated as an independent, autonomous authority. In an increasingly interdisciplinary and sophisticated system, this role of a “personally expert sovereign physician” is no longer tenable [4]. No longer can one individual become a master of every element of anatomy, physiology, pharmacology, and the panoply of other components of complex medical care. With a variety of resources constantly (and literally) at our fingertips, we no longer need to function as a data repository. Instead, we recognize ourselves as a learned intermediary, one who acts as a bridge between a patient and the vast body of constantly improving medical knowledge. Consequently, medical education is shifting toward application rather than acquisition of knowledge. Many schools have integrated problem-based learning classes into the curriculum to facilitate this transition. Rather than focusing on teaching information, we can improve methods of teaching how to find information. These skills are still predicated on an underlying knowledge base; thus, transmission of knowledge remains an important component of medical education. In addition, acquisition of practical skills like interpersonal communication, procedural competency, and critical thinking remains imperative. Pedagogy (from the Greek paidos “child” and ágō “lead,” literally “to lead a child”) has been colloquially equated with teaching. More recently, however, the term andragogy has gained popularity to distinguish

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adult learning [5]. Indeed, adult learning differs from childhood learning in several important ways (Table 1). Although expensive textbooks may still line the offices of many physicians, they can no longer keep pace with the rapid evolution of medical knowledge and have been largely supplanted by other forms of media. In addition to marked increases in the capacity to store information, improvements in technology have improved the way we share this information. Physicians more remote from medical school graduation are less likely to use technology compared with their more contemporary counterparts [6,7]. This may not seem surprising, but it does highlight a potential disconnect between a generation that is teaching and another that is learning. Learners from different backgrounds and environmental influences may receive and assimilate information differently. An increasingly recognized distinction is the difference in learning styles between learners born into different generations (Table 2) [8–11]. For example, learners from Generation X (those born from approximately 1965 to 1980) tend to be more self-oriented, pragmatic, and skeptical. They may respond better to individual learning environments and self-directed activities. In contrast, learners from the Millennial Generation (born 1981-1999) tend toward more community-focused, societal problem solving. They may learn better from collaborative environments and group activities. Of course, there is great potential for overlap between these groups, and no one learning style is ideal for all learners. 3. Flipped classroom The traditional classroom model of education consists of a lecture conducted in front of a group audience, followed by application and problem solving (“homework”) performed individually. In terms of Bloom's educational taxonomy [12,13], this presents a situation in which lowerlevel cognitive functioning like knowledge acquisition occurs in a group setting, whereas higher-level functions like application of knowledge occur individually, when assistance may not be available (Fig. 1). The “flipped classroom” model (also called “flip teaching” or “blended teaching”) [14,15] proposes to have the less interactive lecture-style portions of the curriculum performed individually (eg, an online video), followed by group sessions in which application of the concepts and problem solving can be performed with the instructor's help. This strategy also provides a distinct advantage for learners progressing at different paces. Independently, learners can watch, rewind, or slow down instructional videos. The classroom experience provides an environment to ask for clarification, or pursue more advanced topics. Clintondale High School in Michigan demonstrated successful implementation of this flipped-classroom education strategy throughout their curriculum [16]. This model is particularly well suited for adult learners, and some medical education curricula have already started to use this model [17].

Table 1 Attributes of adult learners Previous knowledge

Self-motivated

Problem-centered

Time-constrained

Building from a preexisting cache of knowledge may enhance the educational experience, but may pose a challenge when introducing new information conflicting with previously held conceptions, or a barrier with illusory superiority [58]. Adult learners are often self-selected for advanced learning opportunities, in contrast to children who may be “required” to attend school. Adult learners tend to focus on more pragmatic aspects of education (problem-solving) and often have difficulty with rote learning. Adults often have more demands on their time outside the learning environment (family, work, etc), which may compromise the time they have to dedicate to learning. Although this may pose a negative influence, it also may cultivate a sense of efficiency.

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4. Simulation We have a duty to provide patient care in accord with our educational goals and must find a balance between “learning opportunities” and optimal patient care. The development of mastery is predicated upon the suggestion that a learner does not inherently have adequate skill to act autonomously. Development takes time, and mistakes may occur [18,19]. In order to mitigate these effects on patient care, one strategy has been to simulate patient encounters. Following the lead of the military and airline industry, evidence for medical simulation demonstrates improved resident performance compared with traditional clinical didactics and can do so in a shorter time frame [20,21]. Beyond clinical management, simulation of procedures may increase knowledge retention and lead to improved patient outcomes [22,23]. The term medical simulation encompasses multiple modalities, including high-fidelity mannequin simulators, partial task trainers, computer-based virtual reality, simulated patients, and simulated environments [24]. The choice of equipment follows teleologically from learning objectives as well as practical issues like cost, availability, and technical support. Medical simulation can be used to support the transmission of tacit knowledge, the translation of explicit knowledge, and the teaching of nontechnical skills such as teamwork, communication, and leadership. It can also be a powerful tool in the assessment of learners [25,26]. Effective simulation is grounded in current educational theory. As an adjunct to clinical experiences and traditional teaching methods, simulated scenarios may provoke emotional activation that ingrains the learning experience [27]. It provides additional opportunities to move through the Kolb cycle of experiential learning (active experimentation leading to concrete experiences, followed by reflective debriefing and the solidification of abstract concepts) [28], without risk of adversity to a patient (Fig. 2). Furthermore, simulation gives educators the ability to offer a comprehensive clinical education, not subject to the variability of time and chance encounters [27]. Every student can be afforded the chance to primarily manage critical patients and rare pathology under the controlled and scheduled tutelage of an instructor [29]. Cases can be graduated and repeated, pushing students through zones of development toward mastery [30]. Finally, it has been demonstrated that simulation as a version of deliberate practice can lead to more effective and lasting results than traditional methods [31,32]. In practice, medical simulation is commonly divided into 3 main phases—prebriefing, simulation, and debriefing [31]. The learning process relies on creating a conducive environment, often described as a “safe” learning space. The prebriefing is pivotal in creating this environment and priming learners for engagement. The simulation scenarios themselves provide the setting for participants to demonstrate and probe the limits of their knowledge, skills, and abilities while the educator observes. Finally, the debriefing phase brings the learner and educator together to discuss reactions and facts, explore knowledge gaps, and provide an opportunity to bridge these gaps. In addition to summative assessment, the feedback given during the debriefing process can be one of the educator's most powerful tools for formative assessment [33]. Unfortunately, there is not yet a great deal of convincing evidence to support or refute the use of simulation for medical education [34]. And simulation is not without its limitations. Over-reliance on simulation may cause exaggerated confidence and deter learners from questioning their decisions. Simulated scenarios may be simplified and miss subtle but important elements. It is not possible to predict or simulate every situation, thus it should be considered an adjunct to other teaching methods. 5. Personal portable electronic devices Personal portable electronic devices (eg, “smartphones” or electronic tablets), with their associated software applications (“apps”), have become ubiquitous in our society. There are more

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Table 2 Differences in generational learners (adapted from Mohr et al [10]) Generation

Personal characteristics

Education characteristics

Communication styles

Response to technology

Traditionalists (1925-1945)

Loyal, reluctant to challenge status quo, dedicated, believe in honor and duty, patriotic Optimistic, desire personal gratification, competitive Independent, self-directed, skeptical, resilient, more accepting of diversity, self-reliant Optimistic, need for praise, collaborative, global outlook

Process-oriented

Formal

Tend not to understand

Dependent, lecture format, processoriented Independent, problem solvers, on-thejob learning, outcome-oriented Team-based, turn to Internet, outcome-oriented

Diplomatic

Not particularly tech-savvy

Blunt

Interested and facile

Polite

Very savvy, view technology as a necessity

Baby Boomers (1945-1964) Generation X (1964-1980) Millennials (1980-1999)

than 40 000 health care–related apps available in the Apple iTunes store alone [34]. In addition to handheld encyclopedic reference and drug dosing (eg, ePocrates, available at http://www.epocrates. com), these devices may provide decision support (eg, Johns Hopkins Antibiotic Guide, available at http://www.hopkinsguides. com) or help with development of a differential diagnosis (eg, Diagnosaurus, available at http://www.unboundmedicine.com/ uguides/diag/diagnosaurus/diagnosaurus.htm). These devices make online calculators (eg, MDCalc, available at http://www.mdcalc.com) practicable for use at the bedside. Media storage has also been revolutionized by “cloud” technology. Remote storage capabilities and file-sharing programs like Evernote (https://evernote. com) and Dropbox (https://www.dropbox.com) improve portability and provide an opportunity to share educational resources easily. Handheld electronic devices can also help augment traditional learning experiences. In addition to providing rapid access to complementary information, technology has been developed to create an interactive environment at the bedside. An example is NearPod, developed for the iOS (iPhone operating system). It is a presentation tool that allows learners to access quizzes, videos, drawings, and so on, through an interactive presentation created and controlled by the teacher during the learning experience. Most educators are familiar with slide presentation software (eg, Microsoft PowerPoint or Apple Keynote), but newer, nonlinear styles of visual aid development (eg, Prezi, available at http://prezi.com) are increasingly popular. In addition, interactive technology like audience response systems (eg, Poll Everywhere, available at http://www.polleverywhere.com) may enhance the traditional lecture experience.

6. Accessibility The near-universal availability of the Internet, coupled with efficient search engines like Google (http://www.google.com), provides rapid access to content but poses the challenge of discerning credibility. Information obtained through such sources may be disseminated very quickly, but sometimes at the expense of accuracy. A recent review of 10 significant medical conditions on the world's most popular general reference site, Wikipedia (http://www. wikipedia.org), found significant discordance between it and another, more selective subscription-based medical review database, UpToDate (http://www.uptodate.com)[35]. On the other hand, the extensive access to publications has the potential to engender a “continuous peer-review process.” Some have called the increased interactive nature of the Internet “Web 2.0,” distinguishing it from the static material originally available on the Internet [36]. Popular weblogs (or “blogs”) have developed using easyto-use technology like Wordpress (http://wordpress.org) and Tumblr (https://www.tumblr.com). Trusted sites, like EMCrit (available at http://www.emcrit.org), welcome comments and additions and continue to update previous entries. Many of these are paired with audio or video presentations, dubbed “podcasts.” Podcasts have developed as episodic series streamed online or through mobile devices (eg, Apple's iPod, hence the moniker) and are increasingly popular [37]. Some are available with a paid subscription, whereas others are free (eg, iCritical Care from SCCM, available at http://www.sccm.org/Communications/ iCritical-Care/Pages/iCritical-Care.aspx). Some of these blogs are even directed at reviewing innovative technology themselves (eg, MedGadget, available at http://www.medgadget.com). 7. Dissemination

Education is not the filling of a pail, but the lighting of a fire. [W. B. Yeats (1865-1939)]

Fig. 1. Bloom's taxonomy [59].

Online educations resources are not unique to the medical community. TED (http://www.ted.com) is a global set of conferences that has made more than 1700 lectures available for free online. The Khan Academy (https://www.khanacademy.org) provides more than 5000 brief lectures on a plethora of topics, focused on providing free educational material. It uses a publicly available video-sharing Web site, YouTube (http://www.youtube.com), to play its videos. In addition to cached lectures, technological advances like Skype (http://www.skype.com) have simplified the process of providing live lectures remotely. Social media services (eg, Facebook, http://www.facebook.com) have become an incredibly popular means of distributing news among the general population, which may translate into dissemination of medical information as well [38,39]. In fact, an annual conference has been established centered on social media and critical care (http://www. smacc.net.au/). Twitter (https://twitter.com) is message-sharing service, which limits messages to 140 characters [40]. In addition to

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Fig. 2. Kolb learning cycle [60].

updating “followers,” these services can be used in creative ways, like creating a running comment stream, collecting questions during a live lecture, or holding a journal club [41]. Some examples of innovative technologies are displayed in Table 3. Over the last decade, there has been an explosive growth of online emergency medicine and critical care resources, from 2 blogs and 1 podcast in 2002 to 141 blogs and 42 podcasts in 2013 [42,43]. “FOAM,” is a term coined by the online medical community, which stands for Free Open Access Meducation (a portmanteau for Medical Education) [43,44]. FOAM refers to a personalized, continually expanding database of resources for medical education (podcasts, blogs, videos, modules, and social media feeds) and represents a novel way of bringing together the global medical community to ask and answer questions pertinent to medical education, research, and best practices. It encourages followers not only to learn the data but also to have an opinion and the capacity to justify it, helping bridge the gap between explicit and tacit knowledge. Learning through FOAM is an active, personalized, and learner­driven process. Learners can seek out information of interest to their practice based on their experiences—either positive (what they find interesting) or negative (where they feel deficient). Many aspects of FOAM differ from traditional learning resources. For one, unlike heavy textbooks, online resources are accessible from any device with Internet capability. Even a few minutes can provide enough time to briefly review a concise blog post. The ease of accessing these resources allows them to transcend the boundaries

of location or setting, and most of these resources are free. FOAM, unlike many other traditional forms of learning, also provides a forum for ongoing conversation. Blog posts allow individuals to comment on the presented material. Discussions and debates about a given topic among individuals around the world can occur over a messaging service (eg, Twitter), similar to an online journal club [45]. FOAM encourages one not only to learn the data but also to have an opinion and the capacity to justify it. Learning through FOAM is also an active, personalized, and learner­driven process. The ease of accessing these resources allows users to transcend geographic constraints. Distinct from many other traditional forms of learning, FOAM provides a forum for ongoing conversation. Blog posts allow individuals to comment on the presented material. Discussions and debates about a given topic can occur over a messaging service (eg, Twitter) like an online journal club [45]. Twitter has become a central medium for the FOAM movement, where a community can interact and educate each other. The “hashtag” #FOAMED is used to search for topics on Twitter and users click on direct links to educational content. “FOAMers” tweet to announce or recommend a new blog post or Web-based resource, ask a question, or provide a response. As far as FOAM use goes, Twitter has been described as a “24-hour-per-day conversation between people who care and are well-informed about their area of practice.” It has also become popular with conferences, enabling people in any part of the world to follow the events live using a #FOAMed hashtag [40].

Table 3 Selected examples of innovative technologya Technology

Example

Description

Advantage

Available at

Mobile Device App Clinical Calculator Podcast Presentation Software

ePocrates MDCalc EMCrit Prezi Dropbox Wordpress TED Talks Facebook Poll Everywhere

Regularly updated, dosing, calculators Searchable, referenced, easy-to-use Variable length, able to subscribe Nonlinear, users can interact with medium Portable, shareable Easy to use, customizable Diverse topics, prominent speakers Wide distribution, popular No need for additional “clickers”

www.epocrates.com www.mdcalc.com www.emcrit.org www.prezi.com

File Sharing Software Blogging Software Online Lectures Social Media Sites Audience Participation Software

Electronic drug reference Online clinical calculator database Serial online audio and/or video publication Cloud-based, zooming user interface presentation software Cloud-based file sharing Web-based software for creating blogs or websites Online collection of educational lectures Social networking service Text-based audience response system

www.dropbox.com www.wordpress.org www.ted.com www.facebook.com www.polleverywhere.com

a A comprehensive review of all products is not possible or practical, and specific examples are provided based on author familiarity and intended only for illustration. No authors report a conflict of interest; there is no sponsorship associated with any of these products. Each of these examples is available without charge.

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Table 4 Definitions relating to assessment [50] Formative Summative Normative Fixed standards Descriptive Quantitative Analytic Synthetic Competence Performance

Evaluation done to shape subsequent performance, Assessment for learning; eg, Feedback on rounds, mid-clerkship reviews Evaluation done at end of unit of time, oftentimes for a “grade,” often “high stakes,” assessment of learning, eg, final rotation evaluations, clerkship grades Relative to peers, eg, “curved” test, evaluations placing learners in quartiles Criterion-based, eg, Milestones, competency-based medical education Narrative, eg, letters of recommendation Numerical, eg, USMLE scores Breaks up assessment into components, eg, checklist rating scales Takes several domains and “puts things together,” eg, “RIME” hierarchy (reporter-interpreter-manager-educator), Global Rating Scales What a student has the ability to do at certain times or under test conditions, eg, OSCE, simulation What a student does in daily clinical practice, eg, clinical evaluations, workplace-based assessment

FOAM is not accredited or peer reviewed, at least not in the traditional sense [46]. Instead, it is managed, populated, and curated by the people involved in the conversation. As with any new technologies, FOAM faces its critiques, challenges, and unanswered questions. Should there be a process of validating content? What are the best online venues through which to provide learning? How can these novel forms of medical education best be integrated into more traditional curricula, and do they actually differ in terms of knowledge retention and improved clinical practice? Ultimately, FOAM encourages the active, self­driven pursuit of knowledge required of life­long learners. 8. Online education Recently, there has been significant notoriety and proliferation of massive open online courses (MOOCs) [47,14]. The general intent of a MOOC is to provide an open-access, distance-learning model with learning activities that typically taking place over the Internet, and a course structured around a set of learning goals in a defined area of study [48]. Instructional design approaches of MOOCs include peerreview, group collaboration and automated feedback by way of quizzes and examinations. Most MOOCs are structured similar to traditional online higher education courses, including a syllabus, and course content typically consists of readings, assignments, and lectures, which are often short (6-12 minutes) “microlectures.” Students watch the lectures, read assigned material, participate in online discussions and forums, and complete quizzes and tests covering the course material. The online activities can be augmented by “face-to-face” meet-ups of MOOC participants using instant messaging or video chat software (eg, Google Hangouts, http://www.google.com/hangouts). They aim to promote active learning based on real-time collaboration and peer learning while also creating an experience mimicking one-on-one tutoring. The range of MOOCs embodies these principles in different ways, and the particulars of how MOOCs function continue to evolve. MOOCs are typically provided by higher education institutions, often in partnership with “organizers” such as Coursera (https://www. coursera.org/), edX (https://www.edx.org), and Udacity (https:// www.udacity.com), and can be either nonprofit or for-profit. The Massachussets Institute of Technology has made nearly all of its course material available online without any charge (http://ocw.mit.edu). The proliferation of MOOCs has arisen from the confluence of several important trends: disruptive ideas about the sources and processes of education (including the growing interest in openness—open access and open resources—in higher education), the development and availability of technologies (including widespread network access), and

educational applications and major changes to the financial model of higher education. In a relatively short time, the activity around MOOCs has challenged long-standing models and premises about education. As evidence of the traction of MOOCs, traditional universities are embracing online courses and investigating ways of making them more effective. Although the initial focus has been on courses related to computer sciences, MOOCS are offered in a wide variety of areas, including medicine with topics like vaccines, public health, biostatistics, and pharmacology [49]. The role of MOOCs in medical education in general and critical care education more specifically is to be determined. Although formal studies evaluating the effectiveness of MOOCs are lacking, they offer new and powerful ways to make learning a lifelong endeavor and more accessible. MOOCs have already shown themselves to be valuable as a kind of workspace or laboratory for innovation, helping uncover new best practices that can be used in other online, blended, or face-to-face settings. 9. Assessment

Never let schooling interfere with education. [Grant Allen (1848-1899)] Assessment is a combination of the processes of evaluation and grading [50]. It has been cited as an integral driver for the development of curricula and the motivations of learners, as well as the currency that ties learners to the curriculum and the curriculum to the system as a whole. To that end, the first question to address is: what is the objective of the learning? Curriculum is guaranteed to fail if the assessment does not align with the objectives and feedback appropriately. Often, these objectives are set by national governing bodies, hospitals or local administrators. An example is the current installment of the Accreditation College of Graduate Medical Education's (ACGME) Milestones. Although an overview of the strengths and weaknesses of various assessment tools has been described, such a review is currently beyond the scope of this review [51]. However, some important definitions can help differentiate various assessment tools (Table 4). In addition, Miller's Pyramid of Assessment (in which levels of assessment— knowing, knowing how, showing, and performing—build upon each other) is a helpful lens through which to view these tools and can be translated for clinician use (Table 5). Finally, when evaluating a proposed assessment instrument, Norcini et al [52] have outlined criteria for good assessment (Table 6). The most important of these criteria is

Table 5 Miller's assessment stratification [57] Miller stratification

Clinical equivalent

Examples of assessment tools

Knows Knows How Shows Does

Clinical knowledge Clinical reasoning Clinical competence Clinical performance

Traditional Multiple Choice Questions (MCQs) Case presentations, essays, extended matching MCQ, Script Concordance Testing OSCE's, simulation scenarios, Standardized Patients, Oral Boards Entrustable professional activities, workplace-based assessments—MiniCEX, Direct Observation, 360 Assessment

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Table 6 Norcini criteria for good assessment [52] 1 2 3 4 5 6 7

Validity or coherence Reproducibility or consistency Equivalence Feasibility Educational effect Catalytic effect Acceptability

There is a body of evidence that is coherent (“hangs together”) and that supports the use of the results of an assessment for a particular purpose. The results of the assessment would be the same if repeated under similar circumstances. The same assessment yields equivalent scores or decisions when administered across different institutions or cycles of testing. The assessment is practical, realistic, and sensible, given the circumstances and context. The assessment motivates those who take it to prepare in a fashion that has educational benefit. The assessment provides results and feedback in a fashion that creates, enhances, and supports education; it drives future learning forward. Stakeholders find the assessment process and results to be credible.

the ability of the assessment to catalyze further learning. Together, these characteristics and frameworks will aid educators in choosing and refining the appropriate The ACGME Milestones were developed as part of the “Next Accreditation System” (NAS) and are an attempt to focus on the outcomes of training rather than the process of training [53] and, thus, reflect a move toward a competency-based system. The Milestones represent a developmental and criterion-based form of assessment that extends from the 6 ACGME competencies, which are both analytic (professionalism, interpersonal skill, knowledge) and synthetic (patient care, system-based practice, practice-based learning and improvement). Competency-based medical education is predicated heavily, although not solely, on significant formative feedback and workplace assessment [54]. One of the explicit goals of the NAS is to create learners with insights and abilities to perform self-directed learning. As such, proponents of the principle of learner-directed objectives have encouraged the use of tools like personal log books and diaries, clinical portfolios, and digital badges as learner-centered tools to track competencies. 10. Accreditation With the advent of online educational resources, credentialing and accountability for these experiences is evolving as well. Traditionally, completion of a standardized curriculum was represented by some sort of certification. This might be a college degree, a certificate for completion of a residency training program, or simply a card attesting completion of a course (eg, Advanced Cardiac Life Support). Unfortunately, a single designation of “complete” does not provide a description of what was actually accomplished. These certifications may be vague, variable, and often difficult to authenticate. As the media for educational experiences evolves and becomes more complex, so must the accompanying credentials. A system of electronic certifications has been proposed, which many have called digital badges[55]. The idea behind this mechanism of credentialing is to provide a greater level of granularity, authenticity, and meaning to the educational experience represents. This could range from individual concepts (eg, placing an IV) to completion of entire curricula. Reviewers could see when learning took place, who was the educator, and precisely what was achieved. An accumulation of these badges could work in accord with the ACGME NAS (Milestones) [53]. A great deal of interest has developed in this arena. The MacArthur Foundation has championed a $2 million grant toward a “Badges for Lifelong Learning Competition,” in conjunction with the Mozilla Foundation [56]. This effort has also attracted the attention of the National Air and Space Administration, Intel Corporation, and the Corporation for Public Broadcasting. TopCoder.com, a competitive computer programming company, has reported digital records like this for years. Openbadges.org is a program created by Mozilla to issue digital badges like this to recognize skills and achievements for companies like the National Air and Space Administration and Disney-Pixar. 11. Conclusions The practice of medicine is evolving at a tremendous pace, and our role as physicians is changing as well. Although we must adapt our own practice, it is important that we recognize our responsibility to

adapt our strategies of teaching as well. Traditional pedagogical teaching methods are not ideal for this rapidly changing environment, and the techniques by which educators were taught are dubious to be ideal for modern learners. Innovative education strategies, like the flipped classroom and online education, are likely to become mainstream. Technology has improved our knowledge repository and translation, but the current scarcity of literature attesting to its utility in the critical care environment points to a greater need for collaboration in the field. Social media, online lecture resources, and a collaborative community can make this information more accessible, as well as foster discussion and development. In the local environment, advances in presentation technology, filesharing, and interactive capabilities can facilitate information translation better than the traditional didactic lecture. Even on an individual basis, technological improvements like rapid access to online calculators and clinical references can help provide improved care for our patients. Simulation has already been adopted in many environments, but its full potential is rarely achieved. Our methods of assessment and accreditation must evolve as well to meet the complexity of our education and provide useful results. In this spirit of collaboration and knowledge dissemination, we hope that this review provides novel and useful educational adjuncts to each reader. If we teach today as we taught yesterday, we rob our children of tomorrow. [John Dewey (1859-1952)]

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