What would happen if learners in developing countries could gain free access to world-class emergency medicine training not otherwise available to them? What if medical students from Stanford University and Makerere University in Uganda could become co-learners? What if digital tools could be leveraged to create inquiry-driven learning experiences that would be impossible otherwise? These were questions Dr. Matthew Strehlow and Dr. S.V. Mahadevan set out to answer last year with their course Surgery 210 – Managing Emergencies: What Every Doctor Must Know.
Dr. Mahadevan and Dr. Strehlow spoke to VPOL after the completion of their course in May. They discuss the format of the course, challenges and successes, and their inspiration for taking the training online.
The challenges that brought the pair to design this course were ones they had seen around the world. As directors of Stanford Emergency Medicine International (SEMI), Dr. Strehlow and Dr. Mahadevan have led trainings for health practitioners in developing countries for over a decade. The need is clear: in Uganda, as in most Low-Middle Income Countries (LMICs), few medical schools offer courses in emergency medicine. Even fewer health care providers have been exposed to basic emergency intervention practices. In contrast, emergency medicine courses are a core requirement at most medical schools in the U.S.
Seminars and week long trainings by groups like SEMI attempt to bridge this gap, but nevertheless have their limitations. They are expensive and their impact is difficult to sustain, as there are almost no specialists in these countries to lead future trainings or provide mentoring. Many health care practitioners are unable to attend seminars because of distance or time away from work, and those who do attend often sacrifice crucial time away from their offices where staffing resources are already spread thin. What’s more, research indicates that these didactic, one-time intensive trainings often do not lead to sustained learning gains. As a result, treatable emergency conditions often go untreated and preventable deaths occur in countries with few or no emergency trainings for medical professionals.
When Dr. Strehlow and Dr. Mahadevan learned about a seed grant competition focused on international online learning, they saw their opportunity. The Office of the Vice Provost for Online Learning (VPOL) and the Office of International Affairs (OIA) awarded their project one of two grants, providing them with financial backing and production and design support. With this aid, the doctors partnered with a university in Uganda to created a novel online course for emergency medicine.
Launched in April 2014, Managing Emergencies was offered simultaneously at Makerere University in Kampala, Uganda and the Stanford School of Medicine. As an international institution with a history of collaboration, Makerere was a natural choice to pilot the course. Dr. Mahadevan and Dr. Strehlow decided to offer the course to Stanford medical students as well to compare the benefits for international and local audiences.
Due to Makerere’s academic calendar, ten weeks of material were compressed into an intensive five-week learning experience. The course modules were presented in video lectures and inquiry-driven case discussions. Video lectures ranging from 10-15 minutes in length covered topics such as fever, burns, and trauma, and skills such as how to manage undifferentiated patients. The instructors invited experts to deliver some lectures and lead the case discussions to provide a variety of expertise and presentation styles.
Dr. Mahadevan in front of Mulago Hospital, the teaching hospital for Makerere University.
For the case studies, students watched a short clip of an emergency scenario from the medical drama TV series ER (a favorite aspect of the course for students, the instructors note). After responding to a series of questions that asked them to analyze the situation and how they would approach it, students were permitted to watch a video of an expert explaining how she would handle the same emergency situation.
In addition to the video lectures and case discussions, the instructional team held a one-day live essential skills training at both Makerere and Stanford to teach some of the critical procedural skills associated with emergency medicine.
The learners took intermittent quizzes to demonstrate their understanding of the material.
Seventy Ugandan students and seventeen Stanford students took the course. This was an impressive turnout, given that the course was new at both universities and the Stanford medical students were taking it for elective credit.
Creating the course was both an opportunity and a challenge for Dr. Mahadevan and Dr. Strehlow. Because their audience was international, they had to design learning experiences to facilitate interaction between U.S. students, Ugandan students, and themselves as instructors. Because their audience was virtual, they had to reformat the material for online video delivery.
First, they collaborated with the VPOL Instructional Design and Pedagogy Team to create modules that would engage students, encourage intellectual curiosity, and build a sense of community. Second, they partnered with the Video Production Team to carefully write scripts, shoot videos, and create a consistent template for guest experts to follow.
Reflecting on working with the pair, VPOL lead instructional designer Andy Saltarelli wrote, “Throughout this process, Drs. Maha and Strehlow dedicated themselves to thoughtfully scripting the case studies and videos, iteratively improving each until polished and aligned clearly with learning objectives. This dedication and attention to detail was absolutely key to the success of the project.
Managing Emergencies instructors Dr. Joe Becker, Dr. Peter Acker, and Dr. Lusana Schutz with Stanford students at the course’s day-long essential skills training.
The Managing Emergencies team is collecting data on the effectiveness of the course. Students completed pre- and post-tests and surveys, and they will complete a retention assessment ninety days after the course’s conclusion. This summer Stanford instructors are teaching a face-to-face (f2f) version of the class at Makerere and using the same assessments to gather data on learning the material in a f2f format. Comparing the outcomes for the three cohorts (Stanford, Makerere online, and Makerere f2f) will yield valuable insights into the impact of the course.
In the end, Dr. Mahadevan and Dr. Strehlow want to answer the following questions: Can online education can address the limitations of in-person trainings in a developing country? Are there benefits to including U.S. students in these online trainings?
Preliminary survey results indicate that students, at least, answer affirmatively to both questions.
One Makerere student wrote, “Looking forward to managing emergencies in my internship…This was an invaluable course and I know more students will benefit from it in the future.”
A Stanford student wrote, “I’m a 3rd year medical student at Stanford, and I’m applying to internal medicine for residency with the eventual goal of practicing oncology. A big part of why I am in medicine is to be able to take care of the people around me in any situation, so a course like this is incredibly relevant to my interests.”
If the course evaluation indicates high impact and benefit for emergency medicine in Uganda, the potential for this format is massive.
An online format allows medical students and physicians to participate from wherever they are, provided they have an internet connection, and removes the pressure on instructors to present all of the content in one day or one week. Students can learn the information in sequenced units over time and practice applying and analyzing new content, stimulating deeper and longer-term learning. The online course materials also remain available to all students so that they can access and apply them later when encountering relevant situations in their practice. The online platform also allows a wider array of teaching strategies, including lecture, case studies, and quizzes. Because the presenters do not have to be there in person, the instructors can bring in a variety of experts in the field. Students can also learn from each other, sharing insights and getting questions answered in the case discussion forums.
Dr. Mahadevan takes notes as guest expert Dr. Kristan Staudenmayer, Assistant Professor of Surgery at Stanford, reviews an ER case study.
The cross-cultural benefits are meaningful, as well. Students in LMICs can learn about technologies that may not be available where they live, but that are likely to appear in the future, given the decrease in cost of medical equipment. U.S. students can learn about alternative perspectives and approaches to problem solving that are crucial for most health practitioners in LMICs, who work in environments where high tech devices and costly tests are rarely available.
Despite the benefits, there are challenges to teaching the training online. Most significantly, instructors cannot demonstrate procedures live or observe students to give feedback. The team attempted to address this issue by holding a one-day live essential skills training, but it remains to be seen whether or not that can adequately serve as a substitute for more extended instruction in person.
Looking ahead, Dr. Strehlow and Dr. Mahadevan are exploring how to share the course content to enhance the education of medical students in other countries. They are interested in customizing the course to include regionally specific topics, and have already spoken with universities in countries such as Pakistan and Cambodia about partnering. They will run the course at Makerere University again, but this time on Makerere’s calendar. Its medical school is interested in making the course a requirement for students, as well.
Makerere medical students and the Stanford teaching team with the dean of Makerere’s School of Medicine, Dr. Harriet Mayanja-Kizza (center left, in red and black blouse).
The results of the tests and surveys taken by Makerere and Stanford students will shape how the instructors move forward with the course, but they are motivated by the initial success they have observed.
In an interview with VPOL, Dr. Mahadevan summed up why there is such a great need for online courses like Managing Emergencies: “Emergency medicine is in its infancy globally…So there’s a real hunger, a real desire, to have access to this really important information.” When health care providers have access to this information, it makes a big difference in the lives of patients.
Witnessing this impact firsthand, the team wants to scale their online trainings. Dr. Mahadevan noted, “If there’s interest from a university in Uganda, clearly there has to be interest from other institutions in Africa, Asia, South America, and other parts of the world.”
OIA and VPOL Announce Winners of Faculty Seed Grants for Online International Learning, Office of International Affairs News
Novel Online Course for Emergency Medicine in Africa and the U.S., Office of International Affairs News
Stanford Seed Grants for Online Learning Highlight International Collaboration, Stanford Report
Faculty Seed Grants, Office of the Vice Provost for Online Learning
Stanford Emergency Medicine International, Stanford School of Medicine
 Moulton, C-A. E., Dubrowski, A., MacRae, H., Graham, B., Grober, E., & Reznick, R. (2006). Teaching surgical skills: what kind of practice makes perfect? A randomized, controlled trial. Annals of Surgery, 244 (3), 400–409.
 Local copies of all course materials were also distributed to learners in Uganda who had slow or unreliable internet connections.