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

EM Stud Podcast – AAMC Standardized Video Interview… Interview (Part 2)


Attention all EM applicants for the 2018 Match!

Beginning this year, all students applying to Emergency Medicine will need to complete an online video interview as part of the ERAS application. This was actually piloted last year, and it is now being rolled out to a broader group of applicants.

For more information about the SVI, we invited back Dr. Atul Grover, Executive VP of the AAMC.

Lots more information available on the AAMC Standardized Video Interview website, including a must-read, The AAMC Standardized Video Interview: Essentials for the ERAS® 2018 Season.

[EM Stud also available via RSS and iTunes]

CDEM Faculty Podcast Episode 5

Episode 5: Finding your Academic Niche   

Hi everyone!  Here is episode 5 of the CDEM Faculty podcast:  Finding your Niche by David Karras.  This talk was recorded at the Philadelphia Education Collaborative and it continues with our theme of finding your path in emergency medicine.  He covers a range of topics such as career options, mentoring, your work environment, and finally how to network.  I hope you all enjoy it as much as I did.


Keep up to date on the latest CDEM Faculty podcast on SoundCloud, RSS, and iTunes.


Suzana Tsao, DO

Director Medical Student Clerkship

Perelman 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. <;.

Presidential Address: Where Do We Go From Here?

The Presidential Address at our SAEM Business Meeting has always been a time to reflect and look forward. This year, we did so framed within CDEM’s 6-point mission.

  1. To advance the education of medical students in the specialty of EM and acute care medicine
  2. To provide a forum for EM clerkship directors and medical student educators to communicate, share ideas and generate solutions to common problems
  3. To foster undergraduate medical education research
  4. To advance the professional development and career satisfaction of EM clerkship directors and medical student educators
  5. To develop relationships with other organizations to promote medical education
  6. To serve as a unified voice for EM clerkship directors and medical student educators

CDEM has advanced each of these missions over the past nine years. Now for the next 3–5 years as we determine where should we put our efforts, I ask: How can CDEM be of most use to you?

1. Advance Undergraduate Medical Education in EM

So far, we published a Clerkship Director’s Handbook, Clerkship Coordinator’s Handbook and Medical Student Primer. We have designed and later refined a fourth-year curriculum in Emergency Medicine and as well as third-year and pediatrics curricula. This was accompanied by two free national exams, an Emergency Medicine shelf exam (collaborating with the NBME), and a curriculum website. Additionally we’ve co-created two videos with EMRA.

Looking forward, the landscape of undergraduate medical education is changing to include entrustable professional activities and milestones while technology gets faster, smaller and more powerful. So how do you think CDEM should keep up?

  • Update the curriculum?
    • Does the CDEM curriculum need to reflect these changes in UME? Can we tailor materials for EM to address all 13 EPA’s?
    • As a fourth year course, should we make EM a capstone assessment of the AAMC’s CEPAERs.
  • Update student materials?
    • The EM Student Clerkship Primer and CDEMcurriculum website, as primarily text based modules, are somewhat passive. Should we add cases, videos, flipped classroom module and assessments to make the material more interactive.
  • Extend our reach earlier into UME?
    • Can we extend EM’s footprint into the M1 and M2 year? For example, we can collaboratively create national clinical reasoning course materials or undergraduate simulation curriculum.

2. A forum to share ideas and generate solutions to common problems

In the past 9 years, we’ve used our list-serv and later the SAEM community to talk with one another. We network at CORD AA and SAEM AA. We have student and faculty blogs, a podcast and 2 Twitter feeds (@CDEMfaculty and @CDEMstudents). In the next few years, how do we share our ideas?

  • Give a bigger footprint?
    • The website currently focuses on student materials. Should we broaden it’s scope while keeping the student content readily available? Or add authors to the blog?
  • Sort out the Academic Assemblies?
    • Admittedly the CORD AA and SAEM AA are fairly close in time (and often space). How can we better tailor each conference to suit our needs?

3. To foster undergraduate medical education research

The WestJEM supplement and new AEM Education + Training journals offer our members publication venues and we have a brand newly established CDEM Scholarship committee.

  • Should we extend our hands to other educational research group to collaborate? Perhaps other members of the Allicance for Clinical Education (ACE)?
  • Should we work with editors of the journals to better delineate what they want to see in our submission to increase the quality of our work and increase the probability of acceptance?
  • Should CDEM endorse surveys to increase exposure and completion rates?
  • How can we better foster research between CDEM members?

4. Professional development

CDEM has provided its members with a national stage for presentations, publication venues, collaboration and leadership in national organizations. The CORD mentoring lunch, pairing senior and junior CD’s, was very successful this year.

A few potential new directions:

  • Include non-member clerkship directors?
    • Any conversation is limited by the fact that there are quite a few clerkship directors not represented in CDEM. How can we bring them into the discussion or encourage to join CDEM? What do they need?
    • Should we develop content and/or cater to core academic faculty who are not in residency or clerkship leadership positions?
  • Create mentoring programs?
    • Would junior members benefit from a long-term mentoring program with more senior members? Senior members could benefit by including this on CV’s for promotion.
    • Most CD’s follow one of a few paths: stay a CD, become a PD (then maybe chair), or enter the dean’s office. Would career specific mentoring help?
  • More stuff for your CV?
    • Should we expand the number and scope of our awards? National recognition helps when it comes time for promotions. For example, receiving an award for “service to CDEM” given to people not on the executive committee but who have put forth a lot of effort on CDEM committees and other projects may look good on a CV.
    • More presentation and leadership opportunities for junior members. The committee structure can serve as a pipeline to CDEM leadership and beyond.
  • Provide professional development for coordinators?
    • the EM Clerkship Coordinators Handbook provides essential information to our coordinators. Should we advance this by providing coordinator specific material?

5. Relationships with other organizations

We currently work with EMRA, CORD, SAEM, AAMC and ACE.  Are there other groups with whom we should be collaborating?

  • Working with SNMA to increase diversity in EM?
  • Working with other SAEM academies?
  • Working with other ACE members (i.e., Neurology Clerkship Directors for stroke modules, COMSEP for Pediatric research).

6. A unified voice for EM UME educators

CDEM acts as the advocate for students on the AAMC Standardized Video project. It was brought up that we change the text of this part of our mission to reflect that we act as advocates for our students.

To serve as a unified voice for EM clerkship directors and medical student educators and advocate for medical students.

  • Additionally, we should push to be involved and informed on topics involving students, like discussions on SVI

Next Steps

These are just a few suggestions stemming from the meeting at SAEM AA 17. CDEM has done a lot nearing the end of its first decade. It will keep growing, and together we can determine in what direction we’ll evolve. Please share your thoughts.

Thank you,

Rahul Patwari, MD
CDEM President 2017–2018

  1. Manthey, David E., et al. “Report of the task force on national fourth year medical student emergency medicine curriculum guide.” Annals of emergency medicine 47.3 (2006): e1-e7.
  2. Manthey, David E., et al. “Emergency medicine clerkship curriculum: an update and revision.” Academic Emergency Medicine 17.6 (2010): 638–643.
  3. Tews, Matthew C., et al. “Developing a Third‐year Emergency Medicine Medical Student Curriculum: A Syllabus of Content.” Academic Emergency Medicine 18.s2 (2011): S36-S40.
  4. Senecal, Emily L., et al. “Anatomy of a clerkship test.” Academic Emergency Medicine 17.s2 (2010): S31-S37.
  5. SAEM Tests,
  6. CDEM Curriculum,
  7. EMRA/CDEM Student Presentation In The ER,
  8. Kwan J, Crampton R, Mogensen LL, Weaver R, van der Vleuten CP, Hu WC. Bridging the gap: a five stage approach for developing specialty-specific entrustable professional activities. BMC Med Educ. 2016 Apr 20;16:117. doi:10.1186/s12909–016–0637-x.
  9. Emergency Medicine Clerkship Primer (2008).
  10. Emergency Medicine Clerkship Coordinators Handbook.
  11. CDEM Faculty Blog:
  12. CDEM Student Blog:
  13. EM Stud Podcast:

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