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The Educational Impact of Weekly E-Mailed Fast Facts and Concepts

In this study, the authors assessed the educational impact of weekly Fast Facts and Concepts (FFAC) e-mails on residents’ knowledge of palliative care topics, self-reported preparedness in palliative care skills, and satisfaction with palliative care education.

The more papers I read, like learning a foreign language, the thinner the blur between mystery and comprehension in terms of judging a paper and its contents. My goal is to be able to conduct such research and write such papers. I understandably feel that a first degree in medicine and a second masters degree in education is required at this level. At best I might be able to take on psychology or neuroscience. My preference and hope would be to become part of a team of experts.

Purpose: Educational interventions such as electives, didactics, and Web-based teaching have been shown to improve residents’ knowledge, attitudes, and skills. However, integrating curricular innovations into residency training is difficult due to limited time, faculty, and cost.

What – A clear problem:

Integrating palliative care into residency training can be limited by the number of trained faculty, financial constraints, and the difficulty of adding educational content with limited resident duty hours. (Claxton et al. p. 475 2011)

Who – Participants

Beginning internal medicine interns

Why – Time- and cost-efficient strategies for creating knowledge transfer are increasingly important. Academic detailing, an educational practice based on behavioral theory, uses concise materials to highlight and repeat essential messages. Soumerai  (1990)

How – We designed this study to assess the educational impact of weekly e-mailed FFAC on
internal medicine interns in three domains: knowledge of palliative care topics, satisfaction with palliative care education, and self-reported preparedness in palliative care skills.


This randomized, controlled study of an educational intervention included components of informed consent, pretest, intervention, and posttest.

Fast Facts and Concepts

FFAC are 1-page, practical, peer-reviewed, evidence-based summaries of key palliative care topics first developed by Eric Warm, M.D., at the University of Cincinnati Internal Medicine Residency Program in 2000.6


One e-mail containing two FFAC was delivered weekly for 32 weeks to interns in the intervention group.


All participants completed a pretest that assessed knowledge of palliative care topics, self-rated preparedness to perform palliative care skills, and satisfaction with palliative care education.

Method: Internal medicine interns at the University of Pittsburgh and Medical College of Wisconsin were randomized to control and intervention groups in July 2009. Pretests and post-tests assessed medical knowledge through 24 multiple choice questions, preparedness on 14 skills via a 4-point Likert scale and satisfaction based on ranking of education quality.

The intervention group received 32 weekly e-mails.

Control Group
No e-mails were sent to the control group.

Respondents completed a post-test 1 to 8 weeks after the

Educational equipoise
All study participants were informed of the content and the online availability of FFAC during recruitment. At the conclusion of the study, both control and intervention groups were given a booklet that contained all the e-mailed FFAC.

Statistical analysis

Descriptive statistics and t tests were used to compare the demographic data between the control and intervention groups. Medical knowledge, preparedness, and satisfaction were compared pretest and post-test within groups by Wilcoxon tests and between groups via Mann-Whitney U tests. The data did not meet assumptions for multivariate analysis due to the small sample size. Only univariate analysis was performed.

Although traditional academic detailing techniques include educational outreach visits and distribution of printed graphic materials, e-learning techniques such as e-mail delivery of educational content, listservs and Web-based tutorials can also be considered rooted in this behavioral theory given their focus on repeated, concise content.

Pain assessment and management, breaking bad news, communicating about care goals, and providing appropriate medical care for a dying patient are necessary skills for surgery, family medicine, pediatric, obstetrics and gynaecology, physical medicine and rehabilitation, emergency medicine, neurology, radiation oncology, anesthesiologist, and psychiatry residents.

Studies that focus on e-mail education interventions have shown that weekly e-mails change the behavior of e-mail recipients, improve learner retention of educational content and that retention improvements increase with the duration over which e-mails were received. (Kerfoot et al. 2007 ) (Matzie et al. 2009)

Results: The study group included 82 interns with a pretest response rate of 100% and post-test response rate of 70%. The intervention group showed greater improvement in knowledge than the control (18% increase compared to 8% in the control group, p = 0.005).

Preparedness in symptom management skills (converting between opioids, differentiating types of pain, treating nausea) improved in the intervention group more than the control group ( p = 0.04, 0.01, and 0.02, respectively).

There were no differences in preparedness in communication skills or satisfaction between the control and intervention groups.

Conclusions: E-mailed FFAC are an educational intervention that increases intern medical knowledge and self-reported preparedness in symptom management skills but not preparedness in communication skills or satisfaction with palliative care education.


Claxton, R, Marks, S, Buranosky, R, Rosielle, D, & Arnold, R 2011, ‘The Educational Impact of Weekly E-Mailed Fast Facts and Concepts’, Journal Of Palliative Medicine, 14, 4, pp. 475-481, Academic Search Complete, EBSCOhost, viewed 25 February 2013.

Matzie KA, Price Kerfoot B, Hafler JP, Breen EM: (2009) Spaced education improved the feedback that surgical residents given to medical students: A randomized trial. Am J Surg 2009;197:252–257.

Price Kerfoot B, DeWolf WC, Masser BA, Church PA, Federman DD: (2007) Spaced educational improves the retention of clinical knowledge by medical students: A randomized controlled trial. Med Educ 2007;41:23–31.

Soumerai SB, Avorn J: (1990) Principles of educational outreach (‘academic detailing’) to improve clinical decision making. JAMA 1990;263:549–556.


Research Terms


The many methods used all have names. In a brave attempt at getting my head around these I’ve started this list for the terms I stumble upon in H809 and related reading.

CRD : A cluster randomised design – by class as it is impractical to teach different things to the same group. (Torgerson and Torgerson 2001. p. 321)
CCT : Case Control Trial – A characteristic of this approach is that the two sets of schools may well be different in a number of aspects other than the intervention being tested, and this may affect the results. i.e. Schools needed to have been either chosen randomly or chosen because the had a similar intake and similar results.
Epistemological : the study or a theory of the nature and grounds of knowledge especially with reference to its limits and validity. (Merriam-Webster)
Ethnography : studying a particular culture by learning to live the life of its members (Hammersley & Atkinson, 1994).
Exploratory RCT: The explanatory trial design is probably the one with which most people are familiar.   (Torgerson and Torgerson 2001. p. 320)
Evidence based research: Randomized Control Trials  (RCT) – as Dr B. Price Kerfoot et al (2006-2012)
Interpretive paradigm: qualitative methods.
IRD. An individual randomised design – as with Spaced Education at Harvard Medical School under Dr. B. Price Kerfoot. (Torgerson and Torgerson 2001. p. 321)
Positivism: a belief in the application of a particular model of the methods of the natural sciences. In Wegerif: verification of hypotheses, numerical measurement, tests of statistical significance and experiments.
The pragmatic RCT : the environment in which the trial is conducted is kept as close to normal educational practice as possible, though the sample has to be far larger to detect smaller changes. (Torgerson and Torgerson 2001. p. 320)
Quantitative: of, relating to, or involving the measurement of quantity or amount. (Merriam-Webster) Coding schemes and publicly verifiable criteria to make categorisations. (Wegerif and Mercer.  1997. p. 271)
Qualitative: of, relating to, or involving quality or kind. (Merriam-Webster) Interpretative method (Torgerson and Torgerson, 2001) Interpretative analysis of transcribed speech = qualitative.  Are the techniques valid? The study of shared knowledge over time. Crook (1994) ‘Qualitative analysis can be effective for generating theories but not so effective for rigorously testing them (Hammersley, 1992).


Hammersley, M. (1992) What’s Wrong with Ethnography. London: Routledge.

Kerfoot.B.P., Yineng Fu, Baker.B., Connelly.D., Ritchey.M.L., Genega.M.G. (2010) Online Spaced Education Generates Transfer and Improves Long-Term Retentionof Diagnostic Skills: A Randomized Controlled Trial, Journal of the American College of Surgeons, Volume 211, Issue ,September 2010, Pages 331-337.e1, ISSN 1072-7515, 10.1016/j.jamcollsurg.2010.04.023.

Torgeson.C.J., and Torgerson.D.J. (2001) The Need for Randomised Controlled Trials in Educational Research British Journal of Educational Studies , Vol. 49, No. 3 (Sep., 2001), pp. 316-328

Serendipity took me to Space Ed when I had just started H807 ‘Innovations in E-learning.’

English: The front of Balliol College as viewe...

English: The front of Balliol College as viewed from Broad Street, looking west. (Photo credit: Wikipedia)

Dr Price Kerfoot is an alumni of Balliol College and he was featured in the College Magazine.

This Balliol and Harvard trained doctor had considered ways to improve the way in which medical students learn. A great deal must be learnt rote, you have to know your anatomy (to start with). This means dissecting a cadaver, making the information stick, then testing yourself relentlessly so that exams can be passed.

Here is a professional educator using e-technology to solve a problem.

As an innovation in e-learning nothing compares. It may not use second life or 3D animation, but is addresses a learning problem and offers an effective solution – good-bye factoids on Rolodex cards, hello 21st century email and text alerts probing you to answer multi-choice questions correctly. If you get it wrong, you receive the right answer and an explanation. This question will be resent in due course and sent repeatedly until it is self-evident that you now know the correct answer.

I’m signed up for Core Anatomy.

I haven’t a clue but using Google and go into research mode. It is staggering the wealth of visual materials to support learning, beautifully rendered images of the human body, podcasts from doctors, definitions of the terminology with audio so you learn how to pronounce these things. I still get the first couple of questions wrong, but never mind. I understand what the right answer is, I am building a corpus of knowledge that will in time enable me to answer 100 questions rather than only 25.

Give it a go.

Better still, build your own Space Ed programme. The platform is free to use and you are free to offer the results of your endeavour for free … or for a fee.



Interactive Spaced-Education to Teach the Physical Examination:

A Randomized Controlled Trial

B. Price Kerfoot, MD EdM1,2,3, Elizabeth G. Armstrong, PhD2,3, and Patricia N. O’Sullivan, MD3,4

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