Educational Technology

Overview

Traditionally at the Stanford School of Medicine, interns and medical students learn by immersion in busy residency services. Residency programs often provide residents with a "pocketbook guide" to carry in their coats. However, the guides are usually more than 100 pages, awkward to carry, and not readily searchable. For these reasons, residents might choose not to carry the pocketbooks, and the appearance of insufficient use can deter some residencies from even creating such a pocketbook.

EdTech wanted to assess the potential usefulness and viability of e-books as replacements for the paper pocketbooks in such real-world settings as the clinics and the bedside. E-books are electronic book files that can be opened using a variety of software and hardware. Software for e-book readers can be desktop- or laptop-based, can be specific to operating systems such as Windows and Mac OSX, or it can be an “app,” which is software typically specific to mobile devices (such as smartphones or tablets) that run a mobile-specific operating system (e.g., Android, iOS). On the hardware side, popular devices such as the Amazon Kindle and Barnes & Noble’s Nook are specifically intended for e-book reading.

E-books

EdTech awarded two hospital residency groups—surgery and pediatric anesthesia—a mini-grant to try creating and publishing e-books as replacements for the traditional pocketbooks. The project focused on the authoring and publishing processes as well as the response of the residents who were to be the eventual users. This led EdTech to assess which document formats (EPUB, MOBI, PDF, etc.) and authoring tools (iBooks Author, Vook, MS Word, etc.) made the best fit for faculty-created content. 

Surgery Residency Handbook (ePUB)

For the surgery residency, the project team created a "Surgery Residency Survival Guide" to address the critical point of transition from clerkships to residency by providing a concise, instantly accessible, action-oriented guide to clinical situations that residents and medical students encounter daily in the surgical wards. Also, to elevate the relevance and utility of the guide in the Stanford context, the last portion of the e-book included logistics and content specific to the Stanford surgical training program, which further orients the trainees and enables them to navigate the system with greater ease and efficiency.

EdTech first met with the project team to analyze and compare several different e-book platforms and created a comparison table of e-book file types and their features, as well as a comparison table of e-book readers and features, and ultimately settled upon the EPUB file format because it is a free and open-source electronic (e-book) standard widely used around the Internet.

EPUB files are readable by a variety of devices and programs, including computers, smartphones, and mobile tablets. The format also supports embedded images and hyperlinks, and many applications support enhanced annotation and navigation functions for browsing EPUB files. By authoring in the EPUB format, users can also easily generate a MOBI file (a file format specifically for the Amazon Kindle application and devices) from source content. The idea was to offer residents the option of using the Amazon Kindle device or application if they preferred. After considering their needs, the team chose the EPUB and MOBI file formats.

Surgery Residency Handbook Screenshots

Authoring Process

We tried numerous software (Apple Pages, Sigil, etc) and online EPUB authoring platforms before ultimately settling upon Vook.com because of the ease with which it allows shared authoring and the publishing of EPUB files, as well as the bonus of outputting MOBI files. Its shared-authoring capability let the content authors work remotely from any web browser and helped expedite both authoring and editing.

However, importing the text from its original source as a Microsoft Word document into Vook’s web interface proved troublesome, especially when it came to nested unordered/ordered lists and Vook’s limited formatting functions/options. 

Ultimately, we were able to work around these issues by editing directly in the EPUB source markup. Dana Yip, the surgical fellow authoring the content for the surgery e-book, summarized the process: “The Vook platform is versatile and relatively straightforward to use... It definitely has some limitations requiring creative ways to organize and display the text. In the end, the product appeared polished and professional.” 

Pediatric Anesthesia (iBooks Author)

For the pediatric anesthesia residency, we created an e-book for residents in the eight-week pediatric anesthesia rotation at Lucile Packard Children’s Hospital at Stanford. The e-book consolidated information from several sources, including an informational website, electronic textbooks, a journal club, and occasional simulation activities. The e-book was designed to provide a site-specific rotation orientation and curriculum that brings the resources of Stanford’s education technology to Stanford-based learners while remaining applicable to any physician training in anesthesia.

Pediatric Anesthesia Handbook Screenshots

Reception and Use

The surgery residency e-book was completed and delivered to all new surgical residents (more than 50 people) in both EPUB and MOBI formats when they arrived in July 2012. Approximately two weeks later, the project team conducted a usage survey, and overall, residents found the guide useful but wished they could have had access to it before starting their surgery residencies, which would have given them more time to review the content before they were inundated with their residency obligations.

• Residents overwhelmingly (94%) said that they would recommend the guide to other surgery residents outside of Stanford.
• Although other apps were also used, 70% of respondents said they used the iBooks app to read their e-books.
• 38% of respondents reported finding the contents of the guide extremely practical (rating of 5/5 on a Likert scale), and the remaining 62 percent said they found the contents very practical or moderately practical (rating of 3/5 and 4/5). No residents reported that the content was not very practical or not practical at all (rating of 1/5 and 2/5).
• 94% percent reported that it was moderately easy (rating of 3/5) to extremely easy (rating of 5/5) to locate a particular topic within the e-book. Only 6% reported that it was not very easy (rating of 2/5 or lower) to locate a particular topic within the e-book.

Although not all EPUB readers support syncing of annotations, we found storing the file on a cloud storage system, such as Dropbox, sufficient for most user situations. We also found that the MOBI file worked well with the Amazon Kindle’s Send-To-Device service and that the annotation sync across devices also worked seamlessly.

Data on the reception of the Pediatric Anesthesiology handbook is not available.

Project Teams

Surgery Residency Handbook

• Dana Lin, MD
• Jamie Tsui
• Jonathan Tatum

Pediatric Anesthesia Guide

• Julie Williamson, DO
• Joe Benfield

Funding

EdTech mini-grants.

Presentations, Publications, and Press

Stanford School of Medicine E-Book Pilots, Educause ELI Brief. January 31, 2013.