 Good morning and welcome to Grand Rounds. I am as excited for this Grand Rounds as I've ever been and I understand the problem of overselling With expectations, but actually I think it's going to be one of our best You're going to see the heart and soul of these two extraordinary talented residents that they've put into this So with that I'm going to turn the time over. I'm not even supposed to moderate this I was just so excited. I wanted to come up and set the mood I'll turn the time over to Sarabha Gunta and Rachel Patel Two people who are making our education much better and goodness. We have a guest in the room. Allie, would you stand up? This is Dr. Allie Simpson. She is a part of our family, but I believe this is your first Grand Rounds you've been with us Welcome high expectations Extraordinarily high will be hard to meet With that turned over to our residents So we're actually just going to take a few minutes at the beginning because I know we gave you guys an assignment Which is this survey that's at most of your stations. If you want to mind taking a couple minutes There are some pens floating around And we especially appreciate if you could just be completely honest with this This is completely anonymous But we're looking to get some feedback before we get started with introduction to this talk Thanks for sharing that, yeah So you had a specific purpose for learning something new and allow you to be self-directed about it as well And you look for different resources on your own And then it makes it enjoyable because you have a project to apply it to and you're going to be teaching it as well So well, thanks for sharing that we'll move on to The next topic here, which is theories of teaching So one of my favorite quotes from a book I started reading recently recommended by Dr. Petty Is how we teach and study is largely a mix of theory, lore, and intuition This is from the book Make It Stick by couple of cognitive Psychologists who are learning or working on developing methods of teaching adults, which is not something that has been studied extensively but It's something that's important for us to know about as faculty and residents who will be teaching adults The one of the one of the comics that they should they mentioned in this book is this one here to those funny So it says Mr. Osborn may I be excused my brain is full I'm sure we felt like this at some point whether we're sitting in a meeting At an international international meeting or even in lecture We know that lecture has the lowest level of retention of all types of teaching And so this this pyramid here exemplifies that I think so This this pyramid exemplifies the levels of retention of knowledge for various types of learning Lecture is the least retention reading after that often times when we read something We just become familiar with the words on the page and how they look and not necessarily understand the topic itself Whereas teaching others and practice doing something allows for the best level of retention We also know that those are more active ways of learning whereas lecture and reading are more passive ways of learning audio auditory and visual Learning is also not as as effective as kinesthetic learning So it's important to think about when we're teaching adults a lot of what we know about teaching adults It's based on what we've seen our mentors do what we've seen our mentors do in medical school and college what we see our mentors do and as when we were in residency, but There are specific ways that we've that have been developed that are more effective for teaching adults So when we think about the terms pedagogy and androgogy pedagogy is a science Art of teaching in general and most of what we know about pedagogy is actually comes from teaching children So pedagogy gives the instructor the main responsibility For making the decisions about learning learning content method and evaluation So when we're a kid when we're in you know middle school high school. We're given a set schedule We show up for class. We show up for history class science class We're given a curriculum who said this is what we're told This is what you have to read on this day This is what you'll be tested on and there's it's a very rigid and structured because Kids don't have as much background coming into thing coming into the topic that they're learnings oftentimes Whereas for adults, it's different. We'll talk about how adults have different types of knowledge coming in but This all ties back to Malcolm Knowles theory of adult learning so Malcolm Knowles was actually an executive director of the Adult Education Association of the United States in the 1950s he was Psychologist philosopher and he developed his theories of adult learning in the 1970s through 90s so As as some of our volunteers mentioned adults need to know why they're learning something So just showing up and not having a reason for why you're there makes it very difficult for us to learn Adults also need to be self-directed. So we need to have some We need to sort of have a responsibility for taking on our own education And we like to seek out our own ways of learning things to some extent but Instructors in this situation act as guides and we're learning something new Adults as as Dr. Mamelis mentioned bring work-related experiences. So sometimes that can Add to learning something new or sometimes it can take away for residents Rachel and I were talking about how this applies to us But oftentimes we'll see a patient coming in with a similar present patient several patients coming in with similar presentations But they might have different diagnoses. So having an instructor or an educator sort of reconcile those things really help so we can Apply those work-related experiences Adults also enter with more of a problem-centered approach, which is why we love case-based learning and problem-based learning Whereas kids they they learn in a subject-centered approach, right? They take their history class or their math class And we love to apply things immediately. So solving a solution solving a problem Right away like following a story following a case is really satisfying and Very and helps us learn one of my favorite theories here is the last one Adults are responsive to some external motivators, but the most potent motivators are internal pressures This is something sort of reflect on on your own So external motivators we're motivated by better jobs Promotions higher salaries, but we're even more motivated by increased job satisfaction self-esteem quality of life peer recognition and Wellness thoughts or concerns about this so far things that they wanted to clarify Well, that's actually a really good point and I think that part of the the change in learning comes not only from the fact that You know this learner was born in 1990s or so which is becoming more of the case But also that we have different tools that are more available for everyone, you know online Pre-work is now more of a possibility And so there there's this whole another way that was totally different than how we used to learn back in the age of Socrates, but we'll get to that. That is a really good point So as we've talked to a lot of you so far and probably we'll be talking to more of you soon about the new Didactic curriculum that we're implementing starting in July of 2020 and We wanted to talk about one of the primary concepts quickly about this new concept and that's the concept of flipped classroom learning I think many of you already familiar with this Flipped classroom learning means that it is a any form of case-based or interactive teaching that is predated by some pre-work Assignments so in contrast to traditional teaching methods where a student is exposed to a topic for the first time during lectures And then has to synthesize it themselves at home afterwards doing their own reading doing their own worksheets a flipped classroom learning approaches things a little differently where the learner will be Complete some pre-work watching a video reading a textbook reading an article Come to class more prepared and participate in more interactive Activities because they've done this pre-work. They're now up at a higher level on that pyramid and can participate in a more Active or blended learning activities So we know that this is something that is new for all of us Residents and faculty and we want to make sure that as we move through this transition that you all feel very supported throughout and so we wanted to Be specific about what outcomes we're looking for provide reasoning for what we're doing What we're envisioning and some examples of how this can play out In the day-to-day didactic curriculum that will be coming next year So we wanted to look a little bit into the literature first about what have faculties perspectives on flipped classroom learning been And so we turn to a couple articles with the first one was this Article that was published in the Journal of Education of perioperative medicine So they interviewed anesthesia faculty from across the United States and asked them about their understanding of Flipped classroom learning and about 60% of them said they had at least a pretty good or solid understanding of what flipped classroom Learning was and of those about 60% of them had employed that model in their own teaching And there was no gender or generational difference in those who felt familiar or had employed it But that actually brings up an interesting question Why is there still this discrepancy between understanding this model and actually implementing it? So the questionnaire went on to ask what are your to you faculty are your perceived barriers to Implementing this flipped classroom model. And so here are some of their answers The colors here the dark blue being that's the there's the percentage of people who strongly agreed with it Read that they somewhat agreed green that the neutral purple that they somewhat disagree etc And so you can see that some of their responses that they agreed with more would be that they're concerned of learners Won't participate or won't prepare for the lecture That it will take too much time to prepare for the first delivery in particular That they might be more comfortable delivering a Lecture the traditional format, but actually a lot of people Disagreed with the fact that they said they they actually did know where to start in the development of a flipped classroom learning We disagree with the fact that they didn't know And so the conclusion of this study was that Several of the barriers many of the barriers that are perceived in utilizing the flip classroom model could actually be Significantly decreased with training and education and then what do residents think so? this was a review article about 22 studies that were published all in the last five years in fact most of them within the last three Years that interviewed residents and faculty from 13 medical subspecialties and overall they found that Residents had a consistently more enjoyable on the experience With a flip classroom learning and the ones who asked faculty said the faculty had more enjoyed like enjoyed teaching with more as well So then the third question is does this work? And this is an evolving process. So there is Some a growing body of evidence to suggest that yes it does That there was for example a meta analysis of 225 Studies that showed that active learning that was involved in flipped classroom learning in science technology engineering on programs was effective or as effective or more effective than Traditional lecture format and also that it decreased the rate of failure of classes that were taught in a more active learning Environment now does this work in GME? This is this is a question that we need to answer There's not enough data on this to show So we're going to now get from the theory to something a little much more concrete And so what does this look like on a day-to-day basis? And so part of this the first part of the process of course is starting off with pre-work What do residents learners do ahead of time to prepare for a didactic morning lecture and so We're going to actually ask you to take out your phone for a second And let's see if this works Okay, so you can either go to the website, but it's probably easier if you text mine And then you'll get a little text message. I've tried this. They don't stand you afterwards So don't worry about that and then you can say a B or C in response So the question would be which of the following homework assignments for example, would you most prefer if you are learning something new? Now some there's no wrong answer here There are lots of different options for pre-work and these are all valid options So journal articles can include review articles can include guidelines for medical management textbook chapters can include Something from the DC SC ones that we've had that have been really excellent have been those where for example, Dr. Simpson has attached her own interactive Like study guide to the glaucoma to a lot of glaucoma chapters Dr. Zabrisky has done a great job of like directing our attention to certain Tables that he found particularly helpful. So like so guided learning within textbook chapter Online modules are possibly for more interactive learning ahead of time videos podcasts We're really blessed with the Moran core as an option for for pre-work assignments Well, that's actually coming quite popular and then quiz or assessment allows for the learners to have a little bit of On some feedback early on even before they come to come to the in-classroom session There's quite a spread. This is kind of interesting. I like it Constantly adjusting cool. Okay So lots of different options in terms of things that can be assigned as pre-work So of course even on this there's been there have been articles published on how to best assign pre-work And what sort of pre-work do residents prefer versus like faculty prefer and things like that So this is a great article that we found published in the pharmacy literature Han colleagues about pre-class learning modules and the best practices for applying these so summarized like these the best practices into four main categories, but there's a more extensive list in the handout that you have that was On your table along with the survey that that you filled out So it's important when assigning pre-work to make sure that the the residents are aware of what they're supposed to be Getting from the pre-work so aligning like pre-class learning modules or materials Having learning objectives essentially ahead of time so that the residents know exactly what they should be focusing on Is really important so that when that when time comes for the in-class discussion Everyone is sort of on the same page as focused on the right topics providing materials in a timely fashion is also important because it lot of these pre-learning Pre-work assignments can take like anywhere between two to four hours to do ahead of time And so and then the quizzes usually at the beginning of an interactive session and people want to make sure that they really know the material well avoiding replicating material from pre-class learning to During in-class learning is also important so that now residents feel especially motivated to continue to do the pre-work ahead of time And you can discuss more higher level Knowledge and application of the material rather than just Understanding or memorizing material and then finally allowing time at the beginning of class for the quiz Questions and a summary of key concepts is important to again build on that to application of the material And there's more in your hand out there, too It's the classroom learning interactive active. These are all different terms I have listed up here that essentially are used interchangeably in the literature and by us as well So put the classroom interactive blended active are all the same I really like this pyramids. It's a little bit different from the other colorful pyramid. We showed you its blooms taxonomy And the way I like to think about pre-work is the fact that it usually has to do with this level of understanding so When we're doing pre-work, it's we're building on our level of understanding by recalling facts and basic concepts and being able to Explain ideas or concepts and then when you come to class, we're working on the top part of the pyramid application Analyzing evaluating and creating. So this is a way to help organize how you approach pre-work versus in-class materials And there are many different methods of interactive learning that we're going to review in class We're in class in during Grand Routes So team-based learning case or problem-based audience response system Which you've already participated in quizzes think-pair share peer-to-peer teaching role playing in games and we'll talk about all of these this will be fun So just wanted to start off with an example of several of these so team-based learning is a concept which let's try out here, so this is a patient a 69-year-old woman who's coming to the ED and I Residents called to see her. This is something that our oculoplastics faculty do really well I'm like for you guys This is mandatory for the residents but optional for the faculty if you wanted to talk to the people next to you In your row or around you and come up with a differential for what could actually present like this? Stretchers are acceptable and so we often use this mnemonic vitamin C So make sure that there you are not missing anything in the idea categories of vascular infectious traumatic Autoimmune metabolic hydrogenic neoplastic and maybe We'll just give you like the 60 seconds to do that So It's a bacterial that's really, really bad for your skin. I mean, it's really bad for your skin. Traumatic is kind of the same as vascular. It's like a direct secyvillation. Okay, the capillary is a little more auto-savvy, a little more uterine, a little bit laterally. Let's see if this feels okay. Yeah, it's a good concept to be on. You can have... You're just like a participant. Alright, we're going to put some people on the spot. So, uh... Okay. We're going to start off with the resident team in the second row. Could you guys name some of your differential, especially for the first couple of options? For the first couple of vascular infectious traumatic? Some of that. So vascular, we said kind of the same as traumatic. We said like cc fistula. Could be. Or you could have bilateral retrobulbar hematomas. And then you could have orbital cellulitis for infectious. Sounds good. Team in the front row. How about any autoimmune, metabolic, idrogenic? So we thought about thyroid, eye disease, and then Wagoner's GPA, granulomatosis. That's a good point, yeah. Orbital pseudotumor and then ITG4 disease. Can't forget ITG4 disease. And then we also thought about... I've seen a lot of patients in the ICU that have chemosis, and so maybe this patient was intubated and their fluid status was, I don't know, really shifted. Bad exposure, keratopathy. Sounds good. Anyone else want to volunteer ideas for the last couple? I don't think congenital really applies as much, but like neoplastic conditions. Very good. Lymphoma's a good one, too. Excellent. So team-based learning is really interesting because each member of a team feels like they have to be accountable to their team. They are put on the spot, but they can talk to their peers first before they are questioned by the instructor. It allows for peer-to-peer learning, so residents at different levels can all contribute something. They can contribute something that they've seen on call, what they've learned about so far. There can be teaching from higher level residents to lower level residents. And this goes along with the general idea of like a social learning theory, that when we're learning among other people, we are more driven. We are more held accountable. It's your buddy. Another quick example of team-based learning. You can take it to even a high level of understanding, even more details by providing like a full case or a series of pictures. Another oculoplastic case here, you have an orbital lesion. You go through the photograph, the imaging, and even the pathology, and you ask the team to discuss what is the diagnosis. What is your approach to resecting the lesion? What nerves and vasculature and muscles should you be aware of? What tools would you want to make sure that you have if you were in the OR? And how would you protect the globe and the optic nerve in this situation? So you can go into as much details you'd like or even have a step-wise approach to team-based learning. You can have multiple choice questions as well and have people raise up cards to give your answers and things like that. Mr. Carson, I didn't know that until Strah told me. Rachel! Sorry. Well, I wasn't sure. You made a difference. I did. It was my vitamin C. Auditor's response is something that you guys have already kind of participated in. To see the elevating eye in torts while the depressing eye acts torts. Here, for example, it's difficult to see the torsional wounds. So this is a... Using auditor's response is something that Dr. C. exemplified for. She gave us the nystagmus video clips. Continuous. And then had us all... And in this patient scene. So, let's... And so, on the same text message that you probably already have participated in, you can actually vote for this one here. Where does Aminaldi causing this type of nystagmus most likely localized? We're going to get you all to learn something today. Y'all are smart. No votes for the lonely medulla? No. So, C-sci must typically paracelar or midline pituitary chiasmal area. You've probably heard of the term peer-to-peer teaching. We've talked about it a little bit with team-based learning already. But this is another example of peer-to-peer teaching. So, pretend you're coming into a didactic session about glaucoma. So for the next didactic session, bring a case of a patient you've treated with severe poag. The PGY-2s will teach us the staging system for poag and how to determine if there is progression of glaucoma. And the PGY-3s will teach us the potential surgical options for this patient and the pros and cons of each. So, peer-to-peer teaching is actually a very effective way to draw on levels of understanding of residents at PGY-2, PGY-3, and PGY-4 levels and sort of build their confidence too and accountability for learning things ahead of time. There are styles of teaching that I just wanted to shout out to a lot of people here who have been great at exemplifying these examples. In pathology, this is Dr. Mamelis as an excellent demonstration of the Socratic method. And that is, I just want you all to appreciate how awesome this is. Schnauz, custody. Schnauz, custody. Schnauz. Oh, Schnauz. We'll see. What Dr. Mamelis does is he'll have a whole bunch of slides with the residents who will come in lined up. That's fine. We'll be lined up in a row and he'll go down the line and ask a couple of questions. What does this look like? How do you remember this? What mnemonics do you have to remember? There are some very predictable ones that we cannot leave this without knowing. And this sort of teaching is especially helpful for when we need to see something, recognize it, repetition, multiple years in a row is critical. What's this? Well, anyway, we have our pathology lectures coming up this month. So if you're all interested, Dr. Mamelis is doing an excellent job starting off next week. So ThinkPairShare is another concept that I came across a couple of years ago or so. And this is a great way to modify the socratic method of just, or like, question sort of and allow residents or learners time to think about a response before they have to answer right away. So this is an example of when we used ThinkPairShare during our journal clubs. So we did a journal club topic on the phase two trial for the neurotrophic growth factor. And we talked about the various stages or various phases of trials by having the residents split up into pairs and then right down phase zero through four what each, the definition of each phase and then have time to make sure they understood it. And then we went around each pair, went around the group and asked each pair what the definition of each of them was. So it's just, it just gives people time to, again, think about a response before they have to be put on the spot, which can be a helpful way of learning and allow for better retention sometimes. There's also the methods of quiz, which most people are already doing an excellent job. Dr. Hartnan and Dr. Chia are two of our faculty who do this really wonderfully. And this can be starting off with a didactic session with a quiz and allowing 10 minutes or so for residents to be held accountable for the pre-work that they've been doing. Then we'll review the answers. So this is my documentation of a quiz I took with Dr. Chia last year in which there was a lot of answers. So we would then go over the quiz and we would actually go over this quiz for a significant amount of time but not just what is the right answer but also using the quiz as a springboard for learning the concept so that when, even if it's a P2I2 resident who's never seen phecoantigenic glaucoma before, phecoanaphylactic glaucoma before, they'll have had this question on it and they have this in mind when they're learning the concept. Role-playing is always a fun way to learn something. This is, it could usually be applied in specific situations though. So role-playing is very helpful when you're learning a new exam technique or new interviewing technique such as motivational interviewing, for example. Dr. Crum actually applied this in her functional or inorganic vision loss lecture last year where she had us get out our phones, bring out the OKN application on the I-hand book and have us test out how difficult it is to not follow the stripes when you have better than 2400 vision. So we're going to demonstrate this now. So we're going to have two of our residents practice role-playing here with the OKN graph. So there's many other tests that you can do. It's just a great role-playing and a great way to just learn new exam skills. So there is a lecture where we're learning mostly new exam skills, for example, like a Pete's lecture. You could even have that lecture in the exam suites. You might even come to the lecture hall necessarily. Games have been a great component of learning recently. Dr. Crum, for example, performed an excellent example of Jeopardy to review neurophthalmology and plastics for O-cups last year. And Jeopardy is very common. So Eric Hansen and Chris Kamansky also converted an FA conference into Jeopardy style. There was candy involved. Brad ate a lot of it. And then we had another Jeopardy quiz last night. And then we also have this was a who wants to be a millionaire lecture that we had in which we learned about different types of diabetic retinopathy and we were asked when we were on the spot what are these questions? Like what is the effect of aspirin on diabetic retinopathy? And what's the definition of high risk PDR? And then you could phone a friend or 50-50, things like that. It was a lot of fun. And then we actually came out with some good learning experience from the end of that. Taboo game was another one that I wanted to try. You know, try to tell your residents to explain a concept if you can't use those words. And then how do we use this to flip the entire didactic session? And so one example of this is what we did recently in her infectious posterior UVitis lecture. So a week ahead of time she gave us a brief little email saying, hey guys, like here is the topics that I want to cover. Gave us a list of those and then some like rare things she wanted to go along she wanted us to learn as well. We had pre-work which included a core lecture courtesy of Dr. Vitale, two review articles and then we had to select two of those rare entities to read a paragraph about. And then when we came to classroom to the in-class session we had a quiz, we reviewed the quiz, we had a discussion to learn some of the concepts. Then we had we broke into small groups and residents would teach each other their rare entities so we could all have some peer-to-peer learning involved there. And then we had an oral board style review with like three minutes put on the spot here's how you do oral boards and learn the concept at the same time. And overall this was just one example of how we can integrate a lot of these different methods into a single hour worth of learning. Do you have any thoughts on any of these ideas or any concerns? If Dr. Cromby would add anything about how millennials like to learn or any other follow-up questions about that I'd be happy to discuss it now or later too. I just have a comment I don't feel like I'm that far out of medical school and yet the curriculum has totally changed when I was there and I thought it was pretty progressive to just have a sort of method of teaching and now there's more than that and I kind of struggled with is this move a transition to adapt teaching to the current learner's preferences or are these just timeless truths about learning and I think it's actually more the latter I think forever active learning has been better than passive learning and I think probably the current generation of learners are just wholly more vulnerable to teach ways that are effective. Not that this is a need to adapt to millennials I thought that for a while or that maybe this is just us trying to adapt to changing generations but I think these are all these have always been more effective ways to teach and to learn and we're just finally kind of catching on and that's kind of my own sort of evolution as I've been teaching with the Medical School and the PA program that they've forced me to change all these ways and I was a little uncomfortable at first but I really think that when you do it after that it's just clear how much better they're actively engaged in synthesizing synthesizing through the lecture That's a really good point thank you Dr. Betty Just to tell off like Griffin I one thing that's interesting in this tension between the millennials and sort of the way we've always done things is within this building we're extraordinary that are lucky this group by definition they're high achievers already and they come in they've gone through the gauntlet of getting into medical school gone through the gauntlet of doing well in medical school and they've arrived at you know again a place where we can tell you we just choose the best of the best that we can and so within this building the challenge is not motivating right these are individuals who will always be more motivated to learn intrinsically than I'm ever going to be able to generate extrinsically and so now it's just capturing that energy motivation intention and making it as we'll just say as positive and as an experience as possible and as effective as possible and so you can see already I mean among faculty we're already doing a lot of extraordinary things and this is just again this ultimately is putting more on your shoulders as residents it's more time for you to have self-directed learning with us as guides and ultimately I mean we've been extraordinarily successful you know again if you don't know this we've got going on seven years first-time board pass rate you know there's nowhere to go but down that's the thing that you guys have to remember with that so as you know as we embark on this you guys are motivated and this is just coming together of two groups who are you know want to be in this growth mindset together I'll take Lydia first and then there was like time to ask questions in the beginning of the seminar and then it would be that open teaching style and then wondering how the pre-work is and that's a really good that's a really good point and I think that that always goes back to one of what Strav talked about in terms of good practices for pre-work that being specific about pre-work of course is very helpful so having questions integrating different types of pre-work we all had different ideas of what we wanted there also are different going to be different flavors of what people are more comfortable with I think that we're going to say that we must do it this way but to encourage people to use their strengths their creativity and draw on that for assigning quizzes ahead of time tables ahead of time case-based studies ahead of time and then using and then you know having all of those possibilities of what people could do as long as they're given out ahead of time and we have time to do them I think that's I don't know is it Philadelphia or Philadelphia but what I've observed in my own department back there is that physicians predominantly practice in the way that they've learned 15 to 30 years before and the question is how do we teach residents who have come through medical school learning particular things that they have to pass an exam and not question those so that they can upgrade by this interactive learning to upgrade practice modes where they have to run in completely epic that has pre formatted kind of things that they have to fill out and how do we develop AI behind this that will assist us in making these updated decisions this is what we need to integrate with interactive learning we need to do this whether it's with vision measurement I recently have been trying to do a vision measurement I went and I questioned 100 people that I thought were the authorities looked at things and what I found out was they're even though they're thinking in new modes they're still practicing the way they did 15 to 30 years ago so how do we transition physicians so they can practice with this questioning attitude so they can update for what they learn from their staff to develop our attention that's it's definitely exactly we need to apply what we're learning in the long term for our work as well I want to touch back base with what Dr. Jardine said real quick one of the things that this make it stick was really helpful for me to realize is that yes maybe it is true that we the way that we're asking to be taught now with active scientists or psychologists is that maybe don't really have like auditory visual learners maybe we're really just adults need to just have recurrent quizzing like we need to consistently be asked questions over and over and over again so that learning is effortful and what we're learning is ingrained in our mind so self quizzing like when you take notes and you're able to fill in the blanks later on and then coming to class and you able to answer those questions going to clinic and going to surgery and be able to answer those questions when the attendings ask you or when you're trying to solve the best way to approach a case and things like that so constant quizzing seems to be more of an effective way for adults to learn and it's really familiar with like that kind of method of teaching but it's really sort of debunked at this point and I think oh sorry we do like to be asked to repeat the information that we should have learned back to you and I find that on rotation when I have medical students with me even if they're really the base knowledge of ophthalmology if I say hey read about anterior nebulitis and I can soar I think they think for that they're like that is the best way to engage throughout the clinic and they really value having these feelings repetitive you know process the questions are going to do that so we're attending on rotation I know we're busy and we don't want to do 10-inch and you read and it's actually in a nice manner a very helpful way just to throw it out there and then you can find the little areas that need to be clarified. So I would encourage faculty to do a few more for residents on a constant basis because that's what active visual learning is like. One idea that we didn't really have time to talk about very much, and I think is in this book as well, is the idea of space to learning as well. Oh, sorry. One idea that we haven't really talked about is that of space learning. So you learn something initially and then you have a trigger to learn it again or remember it again or ask to repeat it again like three days later. And then that gets deeper into our circuits of memory there. And so having both in classroom as well as learning in the clinic, learning in surgery is really helpful to have those different opportunities for space learning there. Yeah, I just wanted to highlight like I think this whole thing with asking questions and I think we can maybe all agree as a resident group like Kamansky's effort of like doing these jeopardies with us. I think it's just like an amazing way like it's a really non volatile environment just with like us residents with a bunch of food like after hours and like him just up there like show any issues like such an awesome way. I think we all walk away from this like our just was so much knowledge because like you said we like he shows us these pictures. We answered the question and then we share our mnemonics. We just did this last night for like two hours like and it was awesome. I think it was like the equivalent to like probably like four hours of studying within that two hours just because we all shared our mnemonics are kind of like weird inappropriate ones that help us like remember these things. So just like this this question based learning like Laverche was saying and what you guys said I think is like so so important. I don't think really any of us mind necessarily being quote unquote pipped. I think it's really helpful. Yeah, we're very lucky to be at this institution where the culture has been moving towards this anyway. I know that we're asking you guys to help us implement it but we are we really appreciate everything that everyone has been doing so far. On that note just wanted to say really briefly what's next. This is the last slide. That is this quiz sorry this survey was surprised was is part of this next step. That is we would like to know how this actually can roll out in a graduate medical education environment in ophthalmology in particular there isn't that much data on there. And so we don't want to end the day you guys with surveys but we really appreciate your honest feedback on this and we look forward to working with you in the future. You are of course I'm going to volunteer myself and probably strive as well if any of you have any questions in the future want to catch us afterwards talk about this more obviously we're nerds about this and so please let us know. A big thank you to the mall attendings and residents and also doctors tag for feedback on our presentation.