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Computer Education in Emergency Medicine Residency Programs

Joilo C. Barbosa, MD, MS* , Paula Willoughby, DO** , Robert G. Mrtek, PhD ***, Craig A. Rosenberg, MD, FACEP*

*Departments of Emergency Medicine and Internal Medicine, **Department of Emergency Medicine SAEM/Physio-Control EMS Fellow, ***Professor, Departments of Medical Education and Pharmacy Administration, University of Illinois at Chicago

Abstract Objective - To determine if and how recent innovations in computer technology have affected the access and usage of computers by emergency medicine residents. To evaluate the status of resident computer training as compared to a previous survey reported and as outlined in the Core Curriculum. Methods -Questionnaires were mailed to the 113 residency program directors listed in the Society for Academic Emergency Medicine (SAEM) home page. Topics queried included current availability of computers, the existence of computer education programs, the status of Internet related activities as well as resident exposure to and actual usage of computers. Results - The response rate was 65% (73/113). The average resident to computer ratio is 6.5:1. While 100% of the programs have computers available for resident use, only 48% offer any kind of formal computer education and only 41% indicate they have an assigned computer educator. Most programs offer some kind of access to the Internet (79%). Software availability is as follows: word-processing (100%), spreadsheets (99%), graphics (96%), literature search programs (96%), databases (88%), statistics (86%), communications (85%) and Internet/commercial network (77%). Resident exposure and usage roughly parallels the availability of software. Conclusion - Computer knowledge in today’s world is a necessity whether one practices medicine as a clinician, researcher, educator, or administrator. Although computers are available for resident use in virtually all programs surveyed, less than half offer formal computer education as recommended by the Core Curriculum. Formal recommendations need to be developed regarding the design and implementation of a computer education program

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Keywords - Computer Literacy, Medical Education, Curriculum Development

Five years have passed since it was recommended in the Core Content for Emergency Medicine that computer education should become an integral part of the training process of emergency medicine residents.1 During this time, the pace of computer technological development has accelerated. The prices of powerful machines have dropped dramatically. The knowledge required to use the basic functions of most of the software available today is limited to a few clicks of a mouse. “Surfing the Net”, “upgrading” and “electronic textbooks” have become commonly used lay terms.

Unfortunately, many physicians continue to be wary of computers. Some even refuse to dedicate the time needed to learn the basics of computing. Consequently, they are frequently unable to take advantage of the benefits offered by these

technological wonders. A general consensus among computer proficient physicians and educators is that “physicians unwilling or unable to utilize these electronic resources will not only not be able to learn in the workplace, they will not be able to successfully cope.”2

Descriptions of successful computer education efforts among health care professionals abounds in the scientific literature, predominantly in the area of nursing.3-6 Medical schools have also described attempts to include such training efforts in their overburdened curricula.7-9 Some published reports have evaluated computer literacy during the residency years,10-12 including emergency medicine.13 It is recognized that computer proficiency is necessary in many areas of medicine:

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administration,14-16 clinical practice,15,17,18 research,19-21 as well as education.22-24

Literature searches, slide making, word processing and lab results retrieval represent just a few of the computer skills residents are expected to have in order to perform daily residency activities. Residency research requirements, if present, can hardly be fulfilled without the assistance of computers. Yet, many trainees enter residency without basic computer skills. At present, efforts to intervene earlier in the educational process have not been completely successful.7,12

It is our intention to describe the current status of computer education and software usage by emergency medicine residents as observed and perceived by residency program directors. It also intended to report whether the progress made in this area, if any, can be compared to a similar survey reported in 1995,25 and if it the changes noted accompany the developments in the field of computers.

Methods

Study Design and Population - On March 26, 1996, a 22 point survey questionnaire was sent to all 113 emergency medicine residency program directors as listed in the SAEM home page (http://www.saem.org/). It covered information regarding inventory and availability of computer equipment, software and other computer resources. It appraised the presence and extent of computer training opportunities made available to residents. It also explored the exposure and use of different types of software. Finally, it evaluated the current status and future plans of each residency in regards to the Internet connectivity, E-mail and home page development. All results represent the opinion and personal observation of program directors.

Data Analysis - Simple descriptive analysis of the data was made after being entered in a spreadsheet. Results were reported in percentages of the total and median and interquartile ranges. The statistical package utilized was SPSS 6.1 for Windows, Chicago, IL.

Results

Seventy three (73) of the 113 survey questionnaires sent to the residency program directors were returned (65%) (Table 1). Forty (40) of the 113 questionnaires were initially sent via mail. This was done in an effort to determine if E-mail is as effective in obtaining results as regular paper mail. The remaining were sent via regular U.S. mail. Of those sent electronically, the E-mail server returned 6 of them as being undeliverable, probably reflecting inaccurate spelling or address changes from the original SAEM list. The returned questionnaires were printed and sent via regular U.S. mail. Of those sent electronically that reached their destination, 17 were returned also via E-mail. The remaining questionnaires originally E-mailed were returned via fax or regular U.S. mail.

The median number of residents in emergency medicine residency programs is 27 with a 25-75% interquartile range of 21-34 (Table 1). Likewise, the total number of computers available and ratio of residents to computers are 3.5 (2-6) and 6.5 (5-12), respectively. This number represents residents to computers in the hospital, not resident owned computers. Most of the programs primarily offer PC environments, although 23% have available both PC and Macintosh computers. Only a minority (4%) use the Mac environment exclusively.

Although all residency programs have computers available for resident use, either in the department or elsewhere in the institution, only 48% of them offer some form of computer education (Table 2). Of all the responding programs, 41% indicated the presence of a computer educator at the program site. This individual is either a computer literate faculty member, research assistant or computer expert.

The availability of individual types of software package is depicted in Table 3. They are, in descending order of availability: word-processing (100%), spreadsheets (99%), graphics and literature search packages (96%), databases (88%), statistics (86%), communications (85%), and Internet/commercial networks (77%). Up to 10% of the residency programs have no statistics packages available for residents. Four percent (4%) of the residency program directors are unaware whether a statistical package is available for resident use (Table

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3, Availability section, Unknown column). Twenty percent (20%) of the programs offer access to neither the Internet nor any other commercial networks.

In spite of the availability of these packages in the residencies, a significant percentage (14-32%) of residency program directors are unaware of whether the trainees have any exposure to specific software packages (Table 3, middle section, column 1 - no exposure). A significant percentage of residency directors are unaware of whether residents are exposed to or make use of certain software packages (Table 3, middle and right sections, columns U -unknown).

The most likely software packages to which residents are reported to have extensive exposure are word-processors, graphics and literature searches (Table 3, middle section). These are also the packages they are most likely use extensively, indicating pressing needs in the preparation of presentations and the need to keep abreast of recent developments (Table 3, right section).

Regarding access to and use of the Internet, 20% of the programs have reported having an informative home page in the World Wide Web. Sixty one percent (61%) have plans to develop one in the near future. The remaining 19% either have no immediate plans or no interest in developing a home page. At the time this study was conducted (March of 1996), 37% of the respondent programs had E-mail capabilities.

Discussion

Educating health professionals in the area of information technology is not a matter of “if”, but of “when,” “how fast” and “at what cost.”26 Nursing as a profession has embraced the laborious task and is now working on developing solutions.3,5,26 With the rapid pace of change in technology, medical school computer education programs have provided only partial solutions for the problem of computer training of students.2,9 It is not uncommon for residents to start residency without even minimal computer skills. This represents an additional source of stress to the resident at the beginning of the clinical training. Because of the lack of successful intervention earlier in the educational process, it then becomes the responsibility of the residency

program to address the issue of fully preparing residents to become professionals, educators and researchers with regard to the efficient use of computers.

The average number of residents per program has remained constant since it was reported in the SAEM Newsletter study in 1995.25 The number of computers has increased from an average of 2.88 to a median of 3.5 (interquartile range of 2-6) (Table 1). The software packages most frequently used in The SAEM Newsletter 1995 report were, in descending order, word processors, graphics, literature searches, data collection, logging procedures and statistical analysis. In the present study, they were: graphics, literature searches, word processors, communications, Internet/Commercial Networks, databases, spreadsheets and statistics.(Table 3)

There has been relatively little progress in the quantity as well as quality of computer hardware available for residents. Similarly, there has been little further progress in the efforts conducted by residency programs to train residents in the use of software efficiently. It has been the authors’ experience that residents are frequently left to fend for themselves in the fulfillment of their requirements as related to computer skills.

While there is high recognition of the importance of the use of computing in daily work, there are insufficient training opportunities to achieve skill levels to satisfy perceived needs as described in the literature,2,10,11 and to allow residents to fulfill their residency requirements such as literature searches, research and the preparation of slides for routine presentations in educational sessions. A significant portion of the perceived needs of residents could be served by offering training opportunities in one integrated office productivity suite (such as Office or Perfect Office)* . Training should highlight the area of across-application compatibility and emphasize the comprehensive nature of such packages in terms of text formatting, graphic presentation, databases and spreadsheet use including built-in basic statistical

*

Office is a trade mark of Microsoft and Perfect Office is a trademark of Corel.

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calculations. Benefits also could be gained from the development of an efficient curriculum emphasizing the fundamentals in electronic communications such as the Internet, E-mail and the World Wide Web.2,27,28

In order to address these issues, a formal curriculum should be formulated which individual residency programs can use as a model for local implementation. In order for any curriculum to be implemented successfully, it must include a consideration of the varying and sometimes diametrically opposing attitudes residents have been shown to have toward computers and computer education.29

Such curriculum needs to be flexible to accommodate various levels of knowledge residents have about computers. It also will have to be adaptable to the quick pace of changes in both software and hardware upgrading developments. For this reason the topical outline should emphasize common productivity uses of computers rather than platform and application specific operations skills. Limitations and Future Questions

Residency directors rather than individual residents were surveyed because of better accessibility as compared to individual residents in all residency programs. It was also the intented to obtain information of availability of computers and software in residency programs rather than individual resident’s access to computers and computer software elsewhere. Additionally, results thus obtained were made comparable with a similar survey performed in 1995. The information reported in this study represents the response from only 65% of the currently listed residency programs. In the 1995 survey there was a 70% response rate.

The results obtained in the present report represent only opinions and observations of residency program directors who may not be aware of daily computer usage by residents. No efforts were made to obtain specific documentation of the topics investigated. No generalizations should be made regarding the situation of computer education and resident exposure to software in the remaining 35% of the programs. The lack of follow up with

non-respondent program directors represents a limitation of the present study.

With the increased global perception of the importance of computers as information management tools, it is possible that program directors may have attempted to compensate for the lack of formal computer training programs by overreporting exposure and actual usage of computers. On the other hand, with the increased prevalence of computer knowledge in younger generations, residents may already be using computers more effectively even without specific computer instruction in residency training programs. This question cannot be answered by this survey. Further studies are warranted that evaluate not only residents’ direct opinions as to what the real needs are, but also the status quo of residents’ computer knowledge and usage.

Conclusions

Computers are a reality in the lives of physicians. Most residency programs appear not to provide adequate exposure and training in computers to meet the professional needs of their residents. Many physicians lack the minimal computer skills needed to confidently face the challenges of practicing medicine as clinicians, administrators, educators and/or researchers. Some of the progress reported between a similar 1995 study and the current findings neither reflects the quick pace nor the development of technology at significantly lower costs for hardware and user-friendly software. This study presents a rather conservative approach to the problem since the non-responding programs may represent a lack of interest of even addressing the issue.

Computer education has been listed in the Core Curriculum for emergency medicine for over five years. Computer skills are described in the literature as being essential for professional success. In their daily activities, residents are expected to perform a number of actions that require frequent use of computers. As described in this study, residency programs have not extensively addressed the issue of availability or adequate exposure and training of residents in the use of computers.

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It is, therefore, important to develop a curriculum that contains general guidelines broadly useful by residency programs planning on establishing computer training programs. Usefulness will depend on curriculum flexibility to accommodate for changes in technology, the various levels of knowledge of computing residents possess and the different existing attitudes towards computers and computer education. Such effort will benefit not only residents but also established educators who may also lack these essential skills.

References

1. American College of Emergency Physicians, American Board of Emergency Medicine, Society for Academic Emergency Medicine. Core content for emergency medicine. Ann Emerg Med 1991;20:920-934.

2. Koschmann T. Medical education and computer literacy: Learning about, through and with computers. Acad Med 1995;70(9):818-821.

3. McGonigle D, Eggers R. Establishing a nursing informatics program. Comp in Nursing 1991;9:184-189.

4. Scarpa R, Smeltzer SC, Jasion B. Attitudes of nurses toward computerization: A replication. Comp in Nursing 1992;10(2):72-80.

5. Kooker BM, Richardson SS. Information revolution in nursing and health care: Educating for tomorrow’s challenge. Sem Nurse Manag 1994;2(2):79-84.

6. Thomas BS, Delaney CW, Weiler K. The affective outcomes of course work on computer technology in nursing. J Nursing Educ 1992;31:165-170.

7. Holmes JL, Lin A, Fath S, Gray L. The paperless essay: one way to teach writing and computer skills in medical school. Med Teacher 1992;14:83-88.

8. Sancho JJ, Gonzalez JC, Patak A, et al. Introducing medical students to medical informatics. Med Educ 1993;24:479-483.

9. Evans LA, Brown JF, Heestand DE. Incorporating computer-based learning in a medical school environment. J Biomed Communic 1994;21:10-17.

10. Robie PW, Kendrick SB, Richards BR. Developing a computer literacy curriculum for residents. Acad Med 1992;67:645-647. 11. Sorkey AJ. Computer literacy in emergency

medicine training: A survey of residency programs. Abstract presented at SAEM meeting, May 1995.

12. Rowe BH, Ryan DT, Therrien S, Mulloy JV. First-year family medicine residents’ use of computers: knowledge, skills and attitudes. Can Med Assoc J 1995;153(3):267-271. 13. Overton DT. A microcomputer application

curriculum for emergency medicine residents using computer-assisted instruction. Ann Emerg Med 1990;19:584-586.

14. Pugh GE, Tan JK. Computerized databases for emergency care: What impact on patient

care? Methods Inf Med 1994;33:507-513. 15. Rodewald LE, Wrenn KD, Slovis CM. A

method for developing and maintaining a powerful but inexpensive computer data base of clinical information about emergency

department patients. Ann Emerg Med 1992;21:41-46.

16. Aghababian RV, Williams KA, Holbrook FA, Lew R. Computer applications in quality assurance. Emerg Med Clin North Am 1992;10:627-647.

17. Hu SC. Computerized monitoring of emergency department flow. Am J Emerg Med 1993;11:8-11.

18. Goldberg RM, Mabee J, Mammone M, et al. A comparison of drug interaction software programs: Applicability to the emergency department. Ann Emerg Med 1994;24:619-625.

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19. Cline D, Henneman P, Van Ligten, et al: A model research curriculum for emergency medicine. Ann Emerg Med 1992;21:184-192. 20. Summers S. Using microcomputers to

facilitate research studies. J Post Anesth Nursing 1992;7(1):48-53.

21. Lachenbruch PA. On using microcomputers in statistical analysis. Statistics 1989;10(9):422-426.

22. DeBehnke DJ, Valley VT. Assessment of the current computer literacy and future computer needs of emergency medicine residents and faculty. Am J Emerg Med 1993;11:371-373. 23. Gonce-Winder C, Kidd RO, Lenz ER.

Optimizing computer-based system use in health professions’ education programs. Comp in Nursing 1993;11(4):197-202.

24. Henry JB. Computers in medical education: Information and knowledge management,

understanding and learning. Human Path 1990;21(10):998-1002,

25. White LF, Jones JS. What do residents know about computers? A national survey of emergency residency programs. SAEM Newsletter 1995.

26. Reynolds A, Ferrell MJ. Computer literacy: A mission for continuing Education for Professional Nurses. J Cont Educ Nursing 1989;20(3):132-135.

27. Frisse ME. Acquiring information management skills. Med Informat 1994;69(10):803-806.

28. Hollander SM, Lanier D. Orientation to the Internet for primary care health professionals. Bull Med Libr Assoc 1995;83(1):96-98. 29. Barbosa JC, Willoughby PJ, Rosenberg CA,

Mrtek RG. Q-Methodology - An objective approach to medical subjectivity. Invited manuscript submitted to the Academic Emergency Journal Medicine 1996. (Accepted for publication, presently undergoing revision).

Address for correspondence: Craig Rosenberg, MD, FACEP

Department of Emergency Medicine (M/C 722) University of Illinois at Chicago

1740 West Taylor Street, Suite 1600 Chicago, Illinois 60612-7233 Fax (312)996-2727

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Table 1

Residency Program Demographics

Respondents 65% (73/113)

Number of years in program

3

4

84%

16%

Number of residents 27 (21-34)* Number of computers available 3.5 (2-6)* Residents/computer ratio 6.5 (5-12)* Types of computer available PC Mac Both 72% 4% 23% *

Median (25-75 interquartile range)

Table 1 - Demographics of residency programs responding to the survey.

Table 2

Respondent Program Computer Profile

Yes No Not known

Computer education 48% 52%

-Computer educator in the program 41% 53% 6%

Computers available for residents 100% -

-Computers available elsewhere other than in the ED 75% 17% 8%

Access to the Internet 79% 16% 5%

Literature searches free of charge 97% 3%

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Table 3

Software Usage Profile

*

Availability

Resident Exposure

Actual Resident Usage

None Extensive None Extensive

Yes No Unknown (U) 1 2 3 4 5 U 1 2 3 4 5 U Word Processing 100 - - 25 12 31 21 11 - - 13 37 28 22 -Spreadsheets 99 - 1 32 30 25 8 5 - 16 40 26 9 3 6 Literature Searches 96 3 1 14 9 32 29 15 1 1 13 32 33 18 3 Graphics 96 3 1 16 14 38 20 12 - - 12 36 26 25 1 Database 88 6 6 33 28 28 8 1 2 6 42 32 9 6 5 Statistics 86 10 4 25 32 32 8 1 2 18 37 30 9 3 3 Communications 85 6 9 26 22 31 12 6 3 12 18 43 13 8 6 Internet/Commercial Network 77 19 4 29 25 25 15 - 6 13 23 42 15 3 4

* - All numbers represent percentages

References

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