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Digital medical education has proliferated in the past decade. Advantages include the ability to offer learners flexibility in time and location of their learning, economies of scale, and the personalization of education. This proliferation coincides with the advent of web 2.0 technologies, such as social networks and collaborative content hubs (eg, wikis). The ease-of-use, availability, flexibility, and free or low-cost software and hosting options make wikis an ideal platform for online education. The term wiki is derived from the Hawaiian word meaning ‘‘quick.’’ A wiki is best described as an interconnected collection of pages that allow for organized end-user creation, modification, and management of the content (eg, Wikipedia). Access to these pages and the ability to edit them can be controlled by the webpage administrator. Wiki content is different from blogs in several aspects, most notably in that content is generated and edited by multiple users. Knowledge thus continuously evolves; content changes by end-users allow rapid improvements that are necessary to keep the content correct and up-to-date. All members of the wiki group have privileges to the material, but usually an administrator maintains oversight. Content changes can occur rapidly and from many authors; therefore, wikis have the ability to track modifications and authorship, with the capability to return to previous versions of a page (known as versioning). This tracking feature supports a degree of personal and group accountability. Why Use a Wiki?

Educators often pose questions about qualitative research. For example, a program director might say: ‘‘I collect data from my residents about their learning experiences in a new longitudinal clinical rotation. If I want to know about their learning experiences, should I use qualitative methods? I have been told that there are many approaches from which to choose. Someone suggested that I use grounded theory, but how do I know this is the best approach? Are there others?’’

Qualitative inquiry is an increasingly popular way of answering important questions in graduate medical education (GME). Qualitative inquiry primarily focuses on the lived experiences of individuals in multidimensional and unique social contexts. It is also used to examine social settings and their affiliated processes. Given these focal areas, qualitative approaches are particularly well suited to answering ‘‘why’’ and ‘‘how’’ questions. Answers to such questions are critical to the exploration and understanding of different social phenomena. For example, GME scholars might ask the following

RIP OUT Creating a Virtual Journal Club: A Community of Practice Using Multiple Social Media Strategies Michelle Lin, MD (@M_Lin) Jonathan Sherbino, MD, MEd (@sherbino) The Challenge Rip Out Action Items Health professions educators should: A journal club provides an opportunity to critically appraise the medical literature and apply it to clinical practice. Traditional, in-person journal clubs face challenges of scheduling participants and facilitators, recruiting local experts, and having a limited, local impact. What Is Known Journal clubs may help develop communities of practice involving ‘‘groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.’’ 1 With the advent of modern digital technologies, online medical-related journal clubs are increasing: partici- pation can be synchronous or asynchronous, experts can be recruited from a global pool, and discussions are digitally archived for broader dissemination. In addition, these journal clubs may disseminate educa- tional innovations and interventions to a wider audience for further study, and they provide rapid feedback to authors regarding similar work occurring elsewhere. These online discourses, however, typically incorporate a single social media strategy, such as Twitter-based journal clubs (#UroJC, 2 #NephJC, http://www.nephjc.com). In an age where we view, engage, and learn from multiple digital streams, a virtual journal club requires a multimodal social media strategy to optimize reach and engagement. In January 2015, a virtual medical education journal club called ‘‘JGME- ALiEM Hot Topics in Medical Education’’ was piloted as a joint collaboration between the Journal of Graduate Medical Education and Academic Life in Emergency Medicine (ALiEM, an education blog with 1.2 million page views per year). 3 This Rip Out describes how to move from hosting an online, single DOI: http://dx.doi.org/10.4300/JGME-D-15-00070.1 Editor’s Note: The online version of this article contains the framework used for the blog post featuring the JGME/ALiEM Hot Topics in Medical Education journal club. 1. Incorporate multiple social media strategies when devel- oping a virtual journal club. 2. Ensure that facilitators are familiar with different social media platforms, including blogs, Twitter, and Google Hangouts on Air videoconferencing. 3. Identify the core team, which consists of at least 4 individuals with unique roles and responsibilities: a primary facilitator, a secondary facilitator/social media expert, a featured author, and an expert discussant. 4. Prepare, host, and conclude the virtual journal club in a 5- stage approach: preparation, promotion, journal club launch, livestream video discussion, and curated dissemination. 5. Use web analytics to trend use and reach as indirect measures of success and impact. platform to a virtual, multimodal journal club by using a blog platform as the central repository of information to house blog comments, embedded Twitter comments, and embedded Google Hangouts on Air video discussions. How You Can Start TODAY 1. Technology platform setup a. Create a (or join an existing) blog. b. Ensure that each facilitator has a Twitter account. c. Create a free YouTube channel to host the livestreamed Google Hangouts on Air video- conference. 2. Build the core team: A minimum of 4 core team members are needed to host a virtual journal club. a. Primary facilitator across the platforms (blog, Twitter, videoconference) b. Secondary facilitator and expert in social media platforms c. Author from the featured journal club pub- lication, to participate in the videoconference discussion d. Topic expert to participate in the videocon- ference discussion Journal of Graduate Medical Education, September 2015

As the Next Accreditation System (NAS) is rolled out, training programs will need to implement a process for continuous faculty development on the use of assessment tools. Reliable assessments of performance by multiple trained faculty are essential to demonstrate resident skill development over time. Yet, with increasing time demands on faculty, fullor half-day training sessions recommended by experts for greater efficacy of training are generally not feasible. Alternately, brief, continuous training, embedded in regularly scheduled meetings, can support ongoing faculty development to help meet NAS requirements.

An age old problem in medical education is supervision and how to do it properly. A variety of methods have been used to improve supervision – from student apprenticeships in the nineteenth century...

Online faculty development (OFD) enables faculty to advance their teaching skills while respecting time constraints. At the 2015 Accreditation Council for Graduate Medical Education workshop on this topic, 57% of participants indicated they have tried OFD, 85% felt that it can be an effective FD method, and 98% believed that it increasingly would be utilized in the future. Yet, gathering the initial capital and technological expertise needed to create OFD can be daunting. This Rip Out presents a number of low-cost resources and strategies that can be used to create an OFD program.

Patricia B. Mullan, PhD, is Professor, Department of Medical Education at University of Michigan School of Medicine; Monica L. Lypson, MD, MHPE, is Associate Professor, Departments of Internal Medicine and Medical Education at University of Michigan School of Medicine. University of Michigan Advisory Committee Sean Smith, MD, Resident Physical Medicine & Rehabilitation; Richard Cohan, MD, Faculty Radiology; Scott Gitlin, MD, Faculty Internal Medicine/Hematology/Oncology; Steven Kasten, MD, Faculty Plastic Surgery; Terry Kowalenko, MD, Faculty Emergency Medicine and Medical Education; Monica Lypson, MD, MHPE, Faculty Internal Medicine and Medical Education/Graduate Medical Education; Mark Prince, MD, Faculty Otolaryngology; Kevin Reynolds, MD, Faculty Obstetrics Gynecology – Gynecology Oncology; Catherine Spires, MS, MD, Faculty Physical Medicine & Rehabilitation; and Paul Dougherty, MD, Faculty Orthopedics.

Faculty and residents are faced with many competing demands on their time, including the need to stay current with the literature and new clinical developments in the specialty. Using technologies available at one’s fingertips allows us to stay current in our fields of interest as clinicians and educators but may seem overwhelming and intimidating at first. To address this challenge, we outline how Twitter can be used as a professional tool to efficiently stay up-to-date in medicine and education.

Problems with clinical reasoning (wrong, delayed, or missed diagnosis and/or treatment) make up a sizable portion of preventable adverse outcomes. In 1 review of diagnostic errors, 75% were at least in part due to cognitive errors. Of 320 cognitive factors identified in 74 cases, 45 were due to faulty data gathering and 264 resulted from errors in problem representation and clinical reasoning. Teaching good clinical reasoning is an important component of resident education.

All authors are at the University of Michigan Medical School. Sarah Middlemas, MPH, is Training Specialist and Director of Graduate Medical Education and Pharmacy Standardized Patient Assessments; Hilary Haftel, MD, MHPE, is Associate Chair and Director of Pediatric Education and Pediatric Residency Director; Paula T. Ross, MA, is Project Manager; Monica L. Lypson, MD, MHPE, is Assistant Dean for Graduate Medical Education and Associate Professor of Internal Medicine.

Allison S. DeKosky, MD, is Instructor of Clinical Medicine at the University of Pennsylvania Health System; Ananya Gangopadhyaya, MD, is Assistant Professor of General Internal Medicine at the University of Illinois Chicago Medical Center; Bobby Chan, MD, practices Family Medicine at MacNeal Hospital; and Vineet M. Arora, MD, MAPP, is Associate Professor of General Internal Medicine at the University of Illinois Chicago Medical Center. Drs DeKosky and Gangopadhyaya contributed equally to this research as joint first authors. Presented in the plenary session at the 2011 Midwest Society for General Internal Medicine Regional Meeting, Chicago, IL, September 15; at the 2012 Association for Hospital Medical Education Conference, Fort Lauderdale, FL, May 18; and as an oral presentation at the 2012 California-Hawaii Society of General Internal Medicine Meeting, San Francisco, CA, January 21.

Maintaining an environment of scholarly inquiry is highlighted in the Accreditation Council for Graduate Medical Education’s (ACGME) common program requirements. Faculty and trainees are expected to participate in scholarly activities, and present those findings to peers for review. Faculty and residents/fellows often lack a conceptual yet practical framework for guiding scholarly activities when they occur in the context of health care systems, clinical practice, quality improvement, education, or community partnerships.

Preeti N. Malani, MD, MSJ, is Associate Professor of Medicine in the Divisions of Infectious Diseases and Geriatric Medicine, University of Michigan Health System, and the Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Ann Arbor Healthcare System; Monica L. Lypson, MD, MHPE, FACP, is Assistant Dean for Graduate Medical Education and Associate Professor of Internal Medicine & Medical Education at the University of Michigan Medical School.

The Rip Out on approaches to reduce diagnostic error in this issue of the Journal of Graduate Medical Education offers practical strategies for defining, teaching, and assessing critical thinking.1 Valuable by itself, this approach can be applied in greater detail to inform curricula, teaching strategies, and resident assessment, using a crosswalk between curricular Milestones2 and the Trowbridge3 12 concepts to avoid errors in clinical reasoning. The detailed curricular Milestones developed by the internal medicine community in 2009 are not the reportable components of the Next Accreditation System currently being implemented by the Accreditation Council for Graduate Medical Education. They represent a very detailed framework of the attainment of competence and can be used to inform curricula and approaches to resident evaluation. Mapping the Trowbridge concepts against the Curricular Milestones identifies at least 28 milestones that capture the knowledge, skills, or attitudes relevant to teaching and assessing critical reasoning (box). Given the relevance of critical reasoning and avoiding diagnostic errors to the range of clinical specialties, the applicability of these concepts goes far beyond internal medicine. Box Crosswalk of the Trowbridge 12 Tips to Avoid Diagnostic Error and the Internal Medicine Milestones •Understand heuristics 1. Medical Knowledge (MK)–A4: Demonstrate sufficient knowledge to diagnose and treat undifferentiated and emergent conditions •Use “diagnostic timeouts” 1. Patient Care (PC)–C3: Modify differential diagnosis and care plan based upon clinical course and data as appropriate 2. Practice-Based Learning and Improvement (PBLI)–F2: Actively seek feedback from all members of the health care team 3. PBLI-F3: Calibrate self-assessment with feedback and other external data 4. PBLI-F4: Reflect on feedback in developing plans for improvement •Think “worst-case scenario medicine” 1. MK-A8: Understand the relevant pathophysiology and basic science for uncommon or complex medical conditions 2. MK-A7: Demonstrate sufficient knowledge to evaluate complex or rare medical conditions and multiple coexistent conditions •Approach common problems systematically 1. PC-C1: Synthesize all available data, including interview, physical examination, and preliminary laboratory data, to define each patient′s central clinical problem 2. MK-A3: Demonstrate sufficient knowledge to evaluate common ambulatory conditions 3. MK-A2: Demonstrate sufficient knowledge to diagnose and treat common conditions that require hospitalization •Ask why 1. PBLI-B2: Classify and precisely articulate clinical questions 2. PBLI-B3: Develop a system to track, pursue, and reflect on clinical questions •Teach/emphasize physical examination 1. PC-A3: Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient 2. PC-B4: Routinely identify subtle or unusual physical findings that may influence clinical decision making, using advanced maneuvers where applicable •Teach Bayesian theory 1. MK-B3: Understand prior probability and test performance characteristics 2. Systems-Based Practice (SBP)—E2: Minimize unnecessary care including tests, procedures, therapies, and ambulatory or hospital encounters 3. SBP-D2: Understand how cost-benefit analysis is applied to patient care (ie, via principles of screening tests and the development of clinical guidelines) •Acknowledge your emotions 1. Professionalism (P)—F4: Recognize and address personal, psychologic, and physical limitations that may affect professional performance 2. P-I2: Recognize and manage conflict when patient values differ from your own 3. P-E3: Recognize and manage subtler conflicts of interest •Identify what doesn′t fit 1. PBLI-E1: Determine whether clinical evidence can be generalized to an individual patient 2. PC-C4: Recognize disease presentations that deviate from common patterns and that require complex decision making •Embrace zebras 1. MK-A8: Understand the relevant pathophysiology and basic science for uncommon or complex medical conditions 2. PC-F9: Manage complex or rare medical conditions •″Slow down″ 1. PBLI-G1: Maintain awareness of the situation in the moment and respond to meet situational needs 2. PBLI-G2: Reflect (in action) when surprised, apply new insights to future clinical scenarios, and reflect (on action) back on the process •Admit mistakes 1. P-A3: Accept personal errors and honestly acknowledge them The added detail provides a framework that identifies granular examples of specific knowledge, skills, and attitudes or behaviors for use in curriculum development and resident assessment. The concepts at the intersection of the Trowbridge more general concepts and the curricular milestones lend themselves to (1) the design of teaching vignettes, (2) drawing attention to particular aspects of these 28 milestones in discussions about the care of patients to avoid diagnostic errors, and (3) using these milestones to inform resident formative assessment, with the added benefit of enhancing the utility and richness of feedback to residents. In summation, the detailed milestones related to critical thinking can serve as the foundation for a more detailed curriculum for critical thinking, as well as provide formative feedback to learners as they develop competence in this vitally important clinical skill.