Audible success

The swine flu pandemic was responsible for widespread morbidity and mortality throughout the world. At its peak in the summer and autumn months of 2009, GP surgeries and emergency departments were besieged by an army of the worried well, the slightly unwell and the seriously ill. The challenge for clinicians was finding out which was which.

At times media reporting seemed to fan the flames of panic surrounding the pandemic, and doctors had to get up to speed quickly on how best to assess, diagnose and treat suspected cases as well as their closest contacts. Some looked for answers on the internet, some contacted the Department of Health and many contacted known providers of learning resources.

At BMJ Learning our initial response to the pandemic was to panic a little ourselves. In response to learner requests, we commissioned experts to write new learning resources as well as update our existing ones, only to find that guidance on how best to manage patients was changing, at times, on a daily basis. This meant that the learning resources were going out of date as quickly as they were being written.

A new approach
After a bit of soul searching we started to produce short and topical learning podcasts on swine flu, initially on a weekly basis. We quickly realised the advantages of the audio format and started to milk these advantages for all they were worth.

Audio is quick to produce, is cheap (and getting cheaper), and the technology to produce it is becoming ubiquitous. You can produce a podcast over the phone and the expert contributor doesn't need to spend hours typing out the review — he simply has to ring-fence an hour of his time to spend with the interviewer.

So what did the learners, ie the doctors and other health professionals, think? In short, they loved it. The pandemic podcasts quickly became our most popular learning resources and stayed that way for a record time. Learners fed back that they found them useful, informative and practical. Additionally, all the modules contained hyperlinks to further resources, which many learners commented they found helpful.

Uptake
We were eager to find out who the learners using the modules actually were. Were they digital natives or a sample of the rest of us? When we first dipped our toes in the waters of multimedia learning resources a number of years ago, it was clear that the highest uptake was among younger users who were most comfortable with the new technology. We expected something similar this time around, and so were surprised when usage statistics showed that the biggest single group of users of the audio learning resources was GPs. The second biggest group was formed of senior hospital doctors. A new technology, the reserve of techies just a few years ago, had become mainstream before our eyes.

We watched the feedback to the resources and saw it change week on week. Following the first few podcasts we received the most amount of noise (pardon the pun) about technology problems: for example: "I don't have the player", "I can't play it" or even "How do I turn the sound up on my computer?" But after the first month or so that type of feedback died away as people became accustomed to the new technology.

Even the late adapters in medicine are now ready for this technology. We started to do all production in-house — and we found that it was possible to do this to a good standard, quickly and cheaply. About one third of users downloaded the podcasts and listened on a mobile device as opposed to listening on the computer. We subsequently received feedback about people learning on the move when driving, running or doing the dishes.

Tweaking a winning formula
We did a lot of reading and research about different formats, as the podcast vehicle was not liked by everyone.

We found that attention spans while listening are fairly short — no-one will listen to anything that is longer than about 20 minutes. We started to provide transcripts of the modules for those who couldn't listen to the audio. We considered audio with scrolling text, but decided against this because, according to educational researchers, you should choose either audio or text and not go for both together. The researchers claim that one or the other is redundant and will overload the learner by flooding both visual and auditory channels at the same time.

We wondered about using music in the background, but again decided against it. Our decision was prompted by the findings of researchers outside medical education, who provided subjects with learning resources with and without background music. The subjects who used the version without the background theme tune achieved significantly higher scores at the end than the group who heard the background music version.

The modules themselves were not universally popular — some learners said that there was nothing new in the modules and some said they were lacking in detail. But interestingly, nearly all of the negative feedback related to content and not to medium. This means either that the quality of sound was fine or that doctors don't care about sound, which would be unusual. Educational research in this area has produced unexpected results: learners are actually more sensitive to the quality of sound than they are to that of video. With audio-only channels, people actively dislike background fuzz and volume levels that rise and fall unpredictably — they expect the same level of consistency and quality as you would get from professional producers.

Another aspect that we considered was whether it was the specific experts we used that people liked or if it was simply the fact that they thought they were listening to 'experts'. Research has shown that learners appreciate listening to the voices of experts such as academics and senior consultants. Learners actually learn more if they feel that the content is being delivered by someone whose expertise and authority they respect.

Towards the end of the series we also developed a panel of experts to contribute, so that more learners would find the content sufficiently challenging. The new panel allowed learners to email, text or call in and put their questions directly to the experts.

Providers and sponsors of continuous medical education constantly speak about the need to engage with learners and to develop long-term relationships with them. Neither of these outcomes is easy to achieve with any group so it is no surprise that some have struggled in this area. Engagement is only really achieved by listening to the target audience and finding out what questions they have, then trying to answer these questions.

There is probably no better way of achieving this deep engagement than by allowing learners to put their questions directly to the great and the good among us. After they have received their answer, ask them if they are satisfied, if their question has been answered and if they want to follow up.

Progression
As the pandemic continued, we continued to produce learning resources and usage remained high. We asked ourselves why: was it the medium or the message? The podcast or the pandemic? We haven't quite worked out the answer to that one yet, but we are starting to think that it is as much the medium as anything else.

We have started to produce audio and video learning resources on obesity, sexual health and cardiovascular disease. These have also been very popular (if any of you write in and say that we have a permanent pandemic of obesity, sexually transmitted diseases and cardiovascular disease, then I will hold up my hands and say you're right; I don't have all the answers).

With regard to long-term engagement, many users tuned in week after week to listen to the latest advice from the educational experts. They liked the fact that they knew their update would come every Monday afternoon at 2 o'clock. Television producers will tell you that having your schedule moved around constantly is the death knell for even the most popular programmes, so why do we constantly arrange off-the-cuff, once-off educational meetings with no follow up? Surely a regular and predictable supply of high-quality education would be more popular and would achieve a more loyal following of learners.

Key learnings
The audio modules we produced proved popular, and were widely accepted as a format. There was a high uptake of relevant learning materials during the pandemic. One of my favourite pieces of feedback was from a GP who told me that it was like Gardeners' Question Time, but on swine flu rather than turnips; that is, an audio experience where the listener has an opportunity to to put his questions to a panel of experts who give their opinions. Because I don't listen to Gardeners' Question Time I have no idea whether this is a compliment or not. Generally, however, I have found that it's for the best to take everything as a compliment.

Some day we may be enlightened, but in the meantime I seriously wonder if an equivalent to Bunny Guinness could be the future of continuous medical education for health professionals.

The Author
Dr Kieran Walsh is editor of BMJ Learning

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