Neurology Education in an Online World

The Neurowiki Experience at Massachusetts General Hospital and Brigham and Women’s Hospital

December 17, 2008

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By Tim W. Yu, MD, PhD, James F. Bartscher, MD, Jay Pathmanathan, MD, PhD, Daniel B. Hoch, PhD, MD

Summary

Current neurology residents and fellows can no longer remember a time in their training without access to the Internet. Every day, trainees turn to online resources for access to journals, medical texts, and other clinical information. These resources are extensive, but vary widely in quality, organization, and target audience. As a result, asking a question and finding an answer may be trivial, but finding the most relevant answer may not. As the volume and diversity of online resources grow, there is an increasing need for physicians to reclaim the time-saving advantages of working online by aggregating and prioritizing the best of these resources.

We believe that the individuals best suited to this task are the physicians themselves. In this spirit, we founded Neurowiki, an online repository of neurology knowledge, created and maintained by neurology residents at Massachusetts General Hospital and Brigham and Women's Hospital. In this article, we present our experience with Neurowiki over the past two years. Based on this experience, we propose that with proper care and feeding, collaborative websites such as wikis can be rich, dynamic resources that are of value not only to neurology trainees, but to the broader neurology community as well.


Neurowiki home page

Introduction

Increasing integration of web-based tools in the medical landscape

The Internet is an important primary source of medical information for both medical trainees and practicing physicians. For more than a decade, familiar websites such as UpToDate, eMedicine, WebMD, and Medline have provided increasingly robust traditional medical content to a broad audience. The easy availability of disease summaries, treatment guidelines, expert opinion, and primary data has led to increased use of these electronic resources in clinical communication and decision-making, but not without new and growing problems of scale and data fidelity.

Of the myriad resources available, which is the most relevant? How reliable is it? How is information kept up-to-date? The birth of a new Internet paradigm—often referred to as "Web 2.0"—has allowed dynamic content to be created and maintained by a community of users. A 2007 survey 1 estimated that 245,000 physicians were already using such resources—defined loosely as posting professional information online or participating in online communities with other physicians—and both the extent and scope of such participation is only expected to grow. Here we report our experiences with an experimental resident-developed, wiki-based Web 2.0 site in medical education, and discuss its potential added value over more traditional Internet modalities as an information distribution platform.

Web 2.0—A new approach to collaboration

The term Web 2.0 (see the article Health 2.0 for Neurologists by Drs. Scherokman and Segal for a more comprehensive discussion)does not apply to any specific technology, but instead refers to the use of existing Internet technologies to bring users together. To do this, Web 2.0 takes advantage of a newer generation of web tools that allow users to dynamically create and change content—thus adding and re-shaping resources based on the ever-changing needs of the community.

Perhaps most prominently, Web 2.0 facilitates social networking. Sites such as Facebook and MySpace allow users to create community-accessible personal content, and have been widely adopted by the current generation in medical training. A 2007 survey reported that over 70 percent of medical students used Facebook, an online service that launched only three years before.2 Another well-known Web 2.0 success story extends the promise of these web-based tools beyond social networking to the realm of information distribution. Wikipedia, an online encyclopedia generated by its users, has grown from its inception in 2001 to one of the largest and most comprehensive references freely available online, with over 75,000 active contributors working together to create a resource used by at least 684 million users yearly (statistics from Wikipedia).

The popularity of sites like Facebook and Wikipedia inspired us to create a neurology-themed collaborative website in May 2006, serving the Partners Neurology Residency community at Brigham and Women's Hospital and Massachusetts General Hospital. Neurowiki* is an online community of residents, staff, and medical students, specifically designed to allow trainees to maximize learning through sharing of common readings, resources, and experiences. The more recent development of medically focused Internet sites such as Medpedia, Wiserwiki, and Knol constitute further evidence of a growing demand for similar, focused collaborative websites tailored to specialized audiences.


* neurowiki.mgh.harvard.edu—a Partners intranet site created in 2006 (not to be confused with other similarly named wikis since posted online). Neurowiki is not currently accessible outside the Harvard firewall.

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Intervention

Neurowiki—Redefining the anatomy of neurology educational resources

The term "wiki" comes from the Hawaiian word for "fast" or "quick." The name was chosen by Ward Cunningham in 1994 to denote a new breed of web software: "the simplest online database that could possibly work." Wikis differ from traditional websites in that online content may be easily contributed to or edited in real time by users, rather than being posted solely through a webmaster. Adding content is made easier through a simple plain-text "mark-up" language, which drastically reduces the complexity of older HTML-based coding (Read more about wiki documents in the Health 2.0 for Neurologists article.) All changes are recorded along with the identity of the author, and previous versions are saved in case edits need to be reversed. Successful wikis encounter surprisingly little in the way of malevolence or vandalism, even in the absence of real security mechanisms, "not because of economic incentives . . . [but] because most people really want the process to work."3

Neurowiki was established as a secure website hosted locally on the Partners network. Content is directly edited by its users, with access restricted to neurology residents, medical students, and faculty. The site hosts content typical of a traditional educational hub: announcements, group calendars, links, resident and medical student survival guides, and teaching materials of all kinds, from user-generated summaries to noontime teaching conference slides.

The inefficiency and disorganization of its predecessors—traditional departmental websites and a shared file servers—fueled resident frustration and served as the driving force behind the creation of Neurowiki.


Michelle, a first-year neurology resident, hurries out of the ER having just seen her fifth patient. In the 15 minutes before noon conference . . .

Read more.

The traditional residency website had the advantage of being easily available from any computer, but its content was relatively static since changes required submission, approval, and, finally, implementation by a webmaster. Predictably, delays and outdated content led to abandonment of this site by the resident community.

The shared file server was initially adopted enthusiastically, and was used as a repository for articles, handouts, pictures and study guides. However, only specially configured computers had access to it. More importantly, it provided little flexibility in organization, and soon became an unforgiving maze of folders and sub-folders, plagued with redundancy and miscategorization. A common complaint was: "I know the information must be there somewhere, but I can never find anything when I need it."

Neurowiki, created in 2006, attempted to preserve and expand the shared database functionality of our local server, while introducing adaptability, improving navigability, and providing independence from IT support. Most importantly, we emphasized collaboration, since knowledge and clinical experience are widely distributed throughout any community.

In establishing the ground rules for Neurowiki, we paid particular attention to security and patient confidentiality. To preserve the greatest degree of freedom for content creation, we decided to protect our wiki behind our institution's firewall, thereby limiting itto those with access to the hospital intranet. Users are required to register for full access and editing privileges, allowing us to monitor for inappropriate changes. A limited guest account is available.

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Functional Anatomy: A wiki in action

Nuts and bolts

Neurowiki was based upon Confluence, a commercial wiki engine chosen for its ease of installation, administrative features, simple wiki markup syntax, and low cost. Numerous other wiki software installations (some free) are also available. Neurowiki runs on an inexpensive Pentium-class server running Windows XP (total hardware cost <$1,000).

Usage

The Neurowiki community at Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital (BWH) consists of over two hundred users, which include faculty, residents, students, and alumni. This community has generated, to date, approximately 750 unique pages of content. Some of the most frequently visited pages have also been the most practical. Atop the list are:

  • Shared calendars
  • Note templates
  • Conference schedules
  • Hospital phone directories
  • Reimbursement procedures for educational expenses
  • Detailed resident survival guides with descriptions of each rotation by year of training

Educational conferences

Residents are exposed to a rich array of educational conferences, but, invariably, busy clinical schedules require them to miss some. To solve this problem, residents store conference materials on Neurowiki, where they are permanently archived for subsequent viewing. For instance, at noon conferences, the chief residents can collect slides and articles from presenters to post them online. Posting is a simple matter of adding an entry on the Conferences page and uploading the relevant PowerPoint and PDF file. For selected lectures, audio can even be recorded and posted to Neurowiki as an audio MP3 file, to be downloaded or accessed online alongside the slides. One of the most successful instances of integrating the wiki with curriculum has been its seamless integration into our weekly neurology clinical-pathological brain-cutting conferences. Neurology residents and neuropathology staff at each of our two main teaching hospitals coordinate these multidisciplinary conferences. Residents prepare a mystery case, usually selected from recent autopsies, and post the clinical protocol on Neurowiki the evening prior to the conference. Also, after each conference, the clinical protocol, relevant imaging, pathology, and follow-up results are posted on Neurowiki. We have built a teaching collection of over 100 adult and pediatric neuropathological cases—work which in the past would have been quickly lost to posterity, but can now be indexed and leveraged for review and future teaching.

Collaborative projects

A recent endeavor has been the development of a Core Curriculum section, which we hope to serve as a residency-wide repository for the most relevant resident-level neurology resources. The goal was not to recreate the content of existing sites and publications, but rather to cull them for what the residents felt was the highest-yield material. Residents were invited to author brief summaries on a list of topics from ischemic stroke to migraine, acute inflammatory demyelinating polyneuropathy to hemifacial spasm. Results were posted in a template format developed by a sub-group of resident "CORE editors," complete with associated links, references, and relevant neuroanatomy. We identified faculty expertsin several areas to oversee sections of the site. An extension of this project will organize and integrate study resources for the AAN Residency In-service Training Exam (RITE) and board review with the aim of creating a succinct but high-yield entry point into local and widely available web-based resources.


Neurowiki features an organized repository for resources gathered/
created by residents over the years

Personal Pages and Data Storage

The Neurowiki also provides personal storage for residents and staff. Site registrants are given personal pages to which they can directly enter notes or upload documents. Like a personal network drive, these materials become accessible to their owners from any location with an Internet connection, but are much more multi-functional than a shared drive alone. It is also simple for this material to be shared.


Page from Neurowiki's library of over 70 Neuropath cases (all data is de-indentified; no patient-specific data allowed throughout the site)

This has proven valuable for teaching, as residents can direct their students to a hypertext-link on their personal page for teaching handouts or articles instead of sending group emails with multiple attachments. Finally, residents also use Neurowiki to post photographs of social events, or to make announcements about upcoming outings.

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Reflections on the Neurowiki experience

Since Neurowiki's inception two years ago, our overall experience has been very positive. Shared information on Neurowiki is much simpler to navigate than the older system of network folders. It has helped cut down on email clutter, as program announcements, lecture notes, and articles are stored centrally instead of languishing in email inboxes. Since it is edited directly by its users, it is updated much more often—and with less effort—than a traditional website. Perhaps most importantly, it has contributed to a sense of community by providing an interactive Internet presence for the students, residents, and faculty it serves.

In its current incarnation, Neurowiki is not without limitations:

  • Maintenance does require some organizational and/or editorial intervention from its administrators ("weeding"). The amount of work required is still much less than a centrally authored website, but it is likely that small-scale wikis such as ours will have a harder time reaching the critical mass of editors to self-police in this respect (e.g., Wikipedia). Our solution has been to identify champions from the Chief Resident group.
  • While attractive from a security standpoint, our decision to secure Neurowiki behind the hospital firewall, means that users may not have access from home except via virtual private network (VPN). It also precludes neurologists and trainees at other institutions from accessing and contributing to Neurowiki.

Despite the current limitations, a remarkable amount of useful content has been generated in a short amount of time—despite the busy schedules of our residents—leading to an indispensable new resource for the local community.

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By Neurologists, For Neurologists

The success of this experiment likely stems, in part, from the fact that residency training programs constitute a particularly close-knit and motivated community with shared experiences, needs, and interests. Such communities are a natural group to seed a wiki.

While Neurowiki and sites like it will flourish best under such fertile conditions, a much larger audience may enjoy the fruits of such efforts. As a first step, teaching resources generated by sites such as Neurowiki can be made accessible to the wider neurology community. Our content is written by neurologists, for neurologists, and is therefore more likely to be directly useful and relevant than resources like Wikipedia.

A more ambitious and potentially more rewarding step will be to open Neurowiki (or similar sites) to the broader community of neurology residents and educators. This would allow the creation of a larger (but still focused) community with common interests in education and neurologic care. Professional organizations such as the AAN may be well suited to host and organize such a resource, given their commitment to resident teaching and continuing medical education.


Resident Survival Guide: Icons and single screen menus
are emphasized in the v.2 redesign of Neurowiki

As evidenced by our time-honored professional gatherings—from local grand rounds to national meetings—physicians rely upon group discussion to compile, redact, and refine their expertise. Because information and experience are dispersed unequally throughout the medical community, collaboration maximizes the fidelity and breadth of education. In a rapidly evolving, high-tech medical world, the Internet has the potential to play a crucial, "democratizing" role in such knowledge-sharing.

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Conclusions

Neurowiki is a resident-initiated intranet resource built by and serving the Partners Neurology residency community. It has proven superior to previous systems of information distribution. We feel that platforms like this have the potential to enhance, centralize, and bring cohesion to the learning experience of neurology residents while encouraging more active, participatory learning.

We propose that broadening these efforts to the wider neurology community could result in a flexible, dynamic, and expert resource accessible to all. Such a resource could become not only an invaluable reference tool but also a way to build community amongst neurologists and to encourage collegiality and collaboration within our profession.

References

  1. Physicians and Web 2.0: Five Things You Should Know about the Evolving Online Landscape for Physicians (Manhattan Research, LLC, 2007)
  2. Sandars J, Homer M, Pell G, Croker T. Web 2.0 and social software: the medical student way of learning. Med Teach 2008 Feb 14:1-5.
  3. Sunstein CR. Infotopia: How Many Minds Produce Knowledge. Oxford Univ Press, U.S. 2006. p. 149.

Related Article

Neurowiki: A Vision of Effective and Efficient Education Through Collaboration (.pdf)—A presentation on the Partners Neurology Resident Project (2006–08) by the authors

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Author Disclosures

Tim W. Yu, MD, PhD (Fellow, Clinical Investigator Training Program, Beth Israel Deaconess Medical Center Assistant in Neurology, MGH; Research Fellow in Genetics, Children’s Hospital Boston) has nothing to disclose.

James F. Bartscher, MD (Stroke & Neurocritical Care, Partners Neurology, Massachusetts General Hospital, Brigham & Women's Hospital, Harvard Medical School) has nothing to disclose.

Jay Pathmanathan, MD, PhD (PGY-4 Resident, BWH/MGH Neurology Residency) has nothing to disclose.

Daniel B. Hoch, PhD, MD (Partners Neurology Residency Training Program and Department of Neurology, Massachusetts General Hospital) has served as an author/editor of material for A.D.A.M. Inc., with compensation of less than $10,000 within the past 24 months. In the same period, he reported that his wife holds stock in Merck and Biogen in excess of $10,000, and he has also offered testimony for the prosecution in criminal proceeding in Essex County, MA, within the past 24 months. Additionally, in the past five years he received intramural research funding from Partners Healthcare to research the potential healthcare applications of virtual worlds. Dr. Hoch has also been the identified PI for funding of Fellow's research into the impact of anticonvulsant medications on interictal spikes and cognitive function in patients with epilepsy; funding for this was provided by UCB Pharma and from the National Epifellows Foundation.