CDEM Voice – Member Highlight


Laura Thompson



Laura Thompson, MD MS

Assistant Professor
Department of Emergency Medicine
OSU Wexner Medical Center


  1. What is your most memorable moment of teaching?

I love the moment when you can help a student figure out if a patient is “sick” or “not sick.” It is an incredibly important teaching point, and after a student has 3-4 years of classroom and clinical learning in med school, it is great to see it all come together.

  1. Who or what has been your greatest influence?

My dad believed in a life of service, and I see education and medicine as two fields that intersect with service to students, patients, and society. My mom always juggled work and family, and has been a role model as I’ve started my career.

  1. Any advice for other clerkship directors?

There is a balance to being a clerkship director – being a student advocate and holding your students to high standards to help them become great physicians. It was initially challenging to be the one to call students out when they weren’t performing well in one area. But I think it is perhaps those students we can help the most – if we can identify the gaps in knowledge or in skills, it becomes so much easier to train the next generation of physicians.

  1. What is your favorite part about being and educator/director?

I love clinical teaching and finding the one or two major points per shift that a student can walk away with a have as a new skill or new skills.

  1. Any interesting factoids you would like to share?

I tell my trainees that you never know where you will learn your leadership skills for running a code or an arrest. When I was a resident, I was in the CTICU on an overnight with a patient in extremis. After things were managed, one of the more seasoned nurses turned to me and said “Were you a coxswain or something??” Indeed – I was a coxswain for about 6 years, and those leadership skills have helped me manage many difficult situations. So, I encourage my mentees to work hard in whatever they pursue, and realize the arenas of work and play are not always so different.


CDEM Voice – FOAMonthly


Stimulating Active Learning: Audience Response Systems

Online Source:

Compared to the traditional passive lecture, active learning methods can increase student participation and motivation, promote critical thinking skills and even increase knowledge retention. Think-pair-share, flipped classroom, gamification, and team based learning are all examples of methods to promote active learning. Unfortunately, consistently incorporating these into the clerkship didactics can be difficult, especially with a rotating set of faculty volunteer lecturers and variable student engagement. One way to promote active learning in a structured didactic format is through the use of audience response systems.

This post, from the ICE blog, provides a nice overview of audience response systems and highlights several audience response technologies. By forcing students to commit to an answer, these systems provide learners with real-time feedback about their knowledge gaps in a low-stakes environment. This can be especially helpful for engaging the quieter students. These systems can also be used to provide accountability for any pre-reading or facilitate team competitions. For the instructor, the class responses can guide the focus of the discussion. More advanced technologies can track a learner’s progress over time to assist with formative feedback. These audience response systems, however, are a tool and not an active learning method in and of themselves. They are not a substitute for well-written questions or effective teaching styles. Nevertheless, this technology can serve as an accessible means to promote active learning and a great resource for colleagues searching for ways to develop more interactive teaching sessions.

Laura Welsh, MD

Medical Education Fellow

Division of Emergency Medicine

University of Washington School of Medicine

CDEM Voice – Topic 360

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“If you want to know how we practiced medicine 5 years ago, read a textbook.
If you want to know how we practiced medicine 2 years ago, read a journal.
If you want to know how we practice medicine now, go to a (good) conference.
If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.”

               – International EM Education Efforts & E-Learning by Joe Lex 2012


Since the movement of Free Open Access Medical Education (FOAM) started in 2012, many emergency practitioners and educators have adopted this concept to disseminate information to the medical community. FOAM is an independent platform that includes but is not restricted to blogs, online videos, twitter hashtags, webpage applications and podcasts. The current trend in education has expanded beyond textbooks, lectures, and peer-reviewed articles. FOAM allows for new and updated medical information to be distributed in a timely manner, anytime, anywhere, with the capability of interacting directly with the authors. FOAM is not just a concept; it has become an ideology.

Despite the growing use of FOAM, there are several professionalism issues that we as educators and researchers need to consider. For instance, who is to be blamed if a medical error occurs from using FOAM in patient care? How can you rate the quality of the information you are reviewing? To investigate these issues, Academic Life in Emergency Medicine introduced the concept of an Approved Instructional Resources (AIR) series. In this series, a nine-person executive board of clinicians created a 5-question rubric score. This tool can be used by medical educators to rate online resources and better evaluate the quality of the information to further help their learners effectively utilize FOAM resources.

Another issue that has not yet been addressed by the medical education community is how to maintain ownership when reviewing, sharing, or creating a FOAM idea. FOAM is defined as “open access,” which means: “free availability to the public internet permitting any user to read and distribute without financial, legal or technical barrier.” This is a beauty and a curse at the same time. Although it provides users unrestricted access to educational materials, it does not provide a copyright to authors over the integrity of their work and the right to be appropriately acknowledged and cited. One might assume that since we are in a highly professional field, users will follow common ethics and professionalism when it comes to sharing and crediting FOAM content. However, there have been instances where an individual publicly shared their innovative idea that was then translated into a successful project by another individual with no mention to the originality of the project.

A discussion on Life in The Fast Lane suggested composing a FOAM charter or a code, whereby FOAM creators register and are given a special “stamp” which indicates that they have adhered to the principles of ethical use and creation of FOAM. However, who should be appointed to the committee remains unclear.

As medical educators, we should discuss these issues with our learners. Until the medical education community comes forward with consensus on its use, we are relying on the current users of FOAM to challenge contributors, question the evidence, and maintain academic integrity.


Layla Salman Abubshait, MD

Medical Education Fellow

Department of Emergency Medicine

Beth Israel Deaconess Medical Center



  1. Chan, Teresa Man-Yee, Andrew Grock, Michael Paddock, Kulamakan Kulasegaram, Lalena M. Yarris, and Michelle Lin. “Examining Reliability and Validity of an Online Score (ALiEM AIR) for Rating Free Open Access Medical Education Resources.” Annals of Emergency Medicine6 (2016): 729-35. Web.
  2. Nickson, Chris. “Time for a FOAM Charter?” Blog post. Life in the Fast Lane. Chris Nickson, 28 July 2013. Web. <;.

CDEM Voice – Research Column



Choosing Wisely: Chi-Square vs. Fisher’s Exact

Choosing the ideal statistical test will help get to the true answer.  Much like in our clinical practice, where we have to weigh the risks and benefits of diagnostic testing, the same holds true in statistical testing.  Every test has its limitations and risk of giving a false positive or negative.  That is why it is important to choose the optimum test.

In educational research, we often find ourselves analyzing data arranged in a contingency table, and then have to choose the “right” test.  Both the Fisher’s exact and Chi-square test can be used.  In order to choose the best test for your data we must understand how the tests work and their limitations.

The chi-square test for independence compares variables in a contingency table.  It is a particularly useful statistic because in addition to determining whether a significant difference is observed it also helps to identify which categories are responsible for those differences.  As a non-parametric test, it does not require assumptions about the distribution the data is drawn from, but does have its own requirements that must be met for a useful and valid result.

To use a chi-square test, the data should be count or frequencies rather than percentages of sufficiently large sample size.  The categories used must be mutually exclusive (for example intervention vs. control group), must be independent and not a paired sample.   There can be only two variables, however for each variable there can be multiple levels (for example the 5-level Likert scale).  Finally, there must be an expected minimum count of at least 5 in at least 80% of the cells in the table.  For instance, in a 2×2 contingency table if one of the four categories has an expected count of less than 5, the chi-square test becomes unreliable. A good rule of thumb is that if the sample size is at least five times the number of cells this should satisfy the final assumption.

While the chi-square is a very useful test to determine if a significant difference is observed, it does not provide much information about the strength or magnitude of the difference.  If a sample size is large enough we can achieve statistical significance even though there is little strength to the association.  To determine the strength of the association a test such as Cramer’s V can be applied.  In addition to the fact that a sufficiently large sample size can yield statistical significance, the chi-square test is also sensitive to small frequencies.  If the expected frequencies in cells are below 5, or more than 20% of cells are below five, the method of approximation used to calculate the chi-square becomes unreliable and risks either a type I or type II error.

The scenario of low expected cell frequencies may be encountered in small sample size educational research or clinical trials.  This is where the Fisher’s Exact test is superior.  The Fisher’s exact test is just that, exact.  It does not use an approximation like the chi-square test and therefore remains valid for small sample sizes.  When the sample size becomes large enough the p-value generated from a chi-square will approach that of a Fisher’s exact.  Fisher’s exact also has the benefit of being valid at large sample sizes.

Historically, statistical tests using approximations such as the chi-square were used because of the arduous calculations required for exact tests.  Now with powerful computers these calculations are easy to perform and generate exact values and do share as significant a risk of type I or type II error due to small sample size.  While typically only used for 2×2 tables, Fisher’s exact can be used with larger contingency tables provided you have ample computing power.

Jason J. Lewis, MD    &    David Schoenfeld, MD, MPH

Beth Israel Deaconess Medical Center/Harvard Medical School



CDEM Voice – FOAMonthly


Curating FOAMed Video Resources for your Students

Featured Sites: Vimeo and YouTube


As seen in the ED…

Attending: The patient in room 12 needs a paracentesis, do you know how to do one?

Student: No, but I watched a video online one time!

The old adage of “see one, do one, teach one,” has now become “watch a video, do one, tell someone else about the video.” Modern medical students are sophisticated navigators of online repositories and increasingly rely on supplemental online resources (i.e. not regulated by you) to complement their learning. Videos can be especially helpful in procedural teaching, but how can we as educators ensure our students are getting exposed to high quality teaching and high fidelity simulations? Thankfully, there’s no need to create fresh quality digital media on your own – there are already numerous open access repositories available. But in that sea of information, how can you curate the collection to best target your learners?

Using online platforms such as Vimeo or YouTube, you can select videos that others have made, add it to a personal collection, and share the collection with your students.  A quick search of “emergency medicine” on either site will show videos from trusted sources such as EMRA, HQMedEd, and specific residency/fellowship programs (as well as some less trustworthy options). If you use Vimeo, it’s simple to create a new group or channel and quickly add videos to it.  To see what I created in less than 5 minutes, follow this link.  A “group” facilitates comments and discussion, while a “channel” is just a playlist of your selected videos.

Ideal for asynchronous learning, a curated collection of videos can also be used to replace a power point presentation filled with embedded videos, or to introduce a procedure before bedside or simulation teaching.  Each group or channel can be public or private (accessible via email invitation on YouTube or shared link on Vimeo), depending on your targeted audience.  Happy curating!


Emily Brumfield, MD

Assistant Professor of Emergency Medicine

Assistant Director of Undergraduate Medical Education

Vanderbilt Department of Emergency Medicine

CDEM Voice – Member Highlight



Nikita K Joshi MD, FACEP

Assistant Clerkship Director, Emergency Medicine

Stanford University

Chief People Office for Academic Life in Emergency Medicine

Twitter – @njoshi8

Email –


1. What is your most memorable moment of teaching?

The most memorable moment of teaching probably is in high school. For some reason I really enjoyed the Kreb cycle and I used to help my friends understand it after school. I even would use a whiteboard to draw out all cycle over and over again. I guess it is pretty clear that I’ve always enjoyed teaching.

2. Who or what is your biggest influence?
Academically speaking, probably one of the greatest influences is Dr. Christopher Doty, my program director in residency. I found him to be a strong and dedicated leader, and someone who continues to inspire me as an educator. Personally, my biggest influence is probably my husband. We met in college and over the years have grown together and shared some pretty awesome experiences. I definitely would not be who I am today without him.

3. Any advice for other clerkship directors?
My advice would be that medical students want to learn and also want to feel appreciated. They want to feel like they are part of the team. This is especially challenging in the busy emergency department, but the worst thing to do is to have faculty and residents ignore the student and make them feel like a burden. Definitely not conducive to learning. No matter how great the curriculum, if the clinical setting is not inviting, then it will not be a good learning experience.blank
4. What is your favorite part about being and educator/director?
My favorite part is to think of new ways to keep the curricula exciting. There’s always new educational technologies and content to consider and add, such as simulation a few years ago and now social media resources. I also love getting inspired by CORD and CDEM for new ideas to shake things up.

5. Any interesting factoids you would like to share?
I am a basketball fan! Which is only natural as I was born in Chapel Hill, North Carolina when Michael Jordan was there playing college basketball. I also grew up in Chicago in the 90s, and got to witness first hand some of the greatest years in NBA history courtesy of Jordan.  I went to college in Cleveland and was privileged to see LeBron James play in a high school game and in the McDonald’s high school all-star game. Now I live in the San Francisco area and get to witness the pretty awesome basketball skills of Steph Curry. Regardless of all the greats there have been and those that will be in the future, I will always believe that Jordan is the greatest player to ever play in the NBA.


CDEM Voice – Topic 360


The Burning Question

A snapshot from the Emergency Medicine Physicians Wellness and Resilience Summit

What is it that separates Emergency Physicians with 30-year-long careers from those who burn out after less than a decade? Why is the rate of burnout higher in our field than in any other medical specialty? What can we do to help stem the epidemic of burnout amongst Emergency Medicine physicians, residents, and students? These questions and many others were tackled at the Emergency Medicine Physicians Wellness and Resilience Summit, held in Dallas in February.


Shanafelt’s eye-opening study in 2015 demonstrated a steadily-rising rate of burnout amongst physicians. This study showed that, between 2011 and 2015, the rate of physicians endorsing at least one symptom of burnout increased from 45% to 54%. The same study revealed that, though Emergency Physicians (EPs) report a higher level of satisfaction with their work-life balance than most specialties, the rate of burnout amongst EPs is the highest of any specialty (Shanafelt 2015). This high level of burnout amongst EPs has been echoed in subsequent studies. The Medscape Lifestyle Study in 2017 re-demonstrated the steadily-increasing rates of burnout amongst all physicians and showed that nearly 60% of Emergency Physicians experience symptoms of burnout, the highest of any specialty.


Even medical students have demonstrated higher levels of burnout than their peers. Brazeau et al demonstrated that matriculating medical students have a lower rate of burnout and depressive symptoms than their age-similar college-graduate peers, but somewhere in medical school that relationship flips, and medical students develop higher levels of burnout and depression than their peers (Brazeau 2014).


There are many reasons why the stressors of medicine, and Emergency Medicine in particular, can cause high rates of burnout and stress. These stressors can vary in importance throughout one’s career. Medical students may find the lack of control and lack of autonomy most frustrating while seasoned providers may be most challenged by the demands of electronic documentation, irregular hours, and lack of administrative support.


The Wellness and Resilience Summit brought together representatives from all of the major Emergency Medicine Groups, including ACEP, AAEM, AACEM, CORD, SAEM, EMRA, RSA, ACGME, and CDEM, to discuss potential solutions to the burnout epidemic. Many ideas were considered as potential areas for intervention or further investigation. All of the findings are currently being written up and will be published to help open a dialogue in our field.


The discussion that focused on our medical students touched on potential initiatives to help teach resilience. More resilient individuals are less susceptible to the stressors of our job and experience less burnout. Emergency Medicine is a stressful field, and we want to give our students and residents the tools they need to have long, rewarding careers. The next step for CDEM is to start investigating the role we can play in mitigating burnout. Through the cooperation of multiple professional organizations, we can help reverse the tide of ever-increasing burnout in our field.


Emily Fisher MD

on behalf of the Emergency Medicine Physicians Wellness and Resilience Summit


Brazeau C, Shanafelt T, Durning S, Massie SF, Eacker A, Moutier C, Satele DV, Sloan JA, Dyrbye LN. Distress Among Matriculating Medical Students Relative to the General Population. Academic Medicine. Nov 2014; 89(11): 1520-1525. doi: 10.1097/ACM.0000000000000482

Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP. Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. Dec 2015;90(12):1600-13. doi: 10.1016/j.mayocp.2015.08.023.