The institutional knowledge required for residency is vast, complex, and frequently changing. Most institutions do not have a resource that serves as a singular source of truth for this information. Furthermore, since information is mostly presented on static documents such as emails or PDFs, there is no easy way to update and share the information in real time. In this article, we present our use of the Notion platform to solve these problems. Using this technology, we created a centralized knowledge hub for the residency. We use this platform to house an intern guide, publish service specific workflows and protocols, and track quality improvement initiatives. While we aim to continually refine the platform, our experience can serve as a template for other institutions attempting to create a one-stop shop for resident productivity and well-being.
Surgical residents are responsible for learning and remembering a vast amount of information. While much of this information relates to the science and practice of surgery, a large portion is institutional and related to process. Most institutions do not maintain this information in a centralized and accessible format. Though exploratory conversations and surveys, we found that information was often organized piece-meal across a combination of paper, email, and cloud platforms such as Google Drive, WhatsApp, or Dropbox. While some programs did have central knowledge platforms, they were difficult to update in real-time. Here, we present our vision for a digital source-of-truth for such institutional knowledge - an operating system for residency.
First, we analyzed the pain points that residents experienced accessing and organizing institutional knowledge. This information was previously siloed on multiple different platforms. Service and surgeon-specific protocols were uploaded to Google Drive, buried in text threads, or printed on paper depending on the service. Finding administrative forms often required searching through emails. Resident and faculty contacts were available on a Google sheet while hospital numbers were printed on a paper card. Furthermore, when such information could be found, it was often out-of-date, as no mechanism existed to update and disseminate knowledge in real-time.
After evaluating these pain points, we developed the following user requirements to guide the design of a new platform. First, the solution had to be mobile-friendly - as residents always have their phones on hand. Second, the solution had to be easy to update - as the annual review process previously in place was inconsistent and left too many outdated protocols in circulation. Third, the solution had to be intuitive - easy to use with minimal training. Fourth, the solution had to be low cost - as there was no funding for this project.
There are multiple software options that offer the functionalities we were looking for. Ultimately, we decided to use Notion to build our platform. Notion allows users to build custom, collaborative workspaces consisting of documents and databases. It is used by individuals and organizations across industries to create wikis, manage projects, write documents, and build internal tools. It is available as a web, desktop, and mobile application. Users can update any of the content in real-time. Notion is offered for free to educational institutions for up to 100 guest users at present. Additional features are available at a charge. Perhaps its most useful feature is the ability to update information in one place and have that update reflected elsewhere. For example, if you update a surgeon's email address on the 'Contacts' page, the updated address will automatically appear on the pages of any services or committees with which that surgeon is affiliated. As such, there is always a single source of truth for any piece of information.
Implementation of the Platform
First, we created a digital version of our 'Intern Survival Guide.' Each topic from the physical paper guide – representing a clinical scenario that an intern may encounter – was transformed into a digital card containing the relevant steps in triage and work up. Issues requiring escalation to a senior resident or attending surgeon were highlighted.
Next, the disjointed resources containing service-specific protocols were adapted to the Notion platform. In a multi-week effort, content was systematically transferred, and post-operative protocols were standardized in a tabular format. Tutorials detailing how to enact these protocols in the electronic health record (EHR) were constructed in parallel - including step-by-step screenshots of common tasks including pre-rounding, placing orders, and admitting or discharging patients.
Next, the contact directory was migrated to Notion. This effort consolidated information that was previously housed on Google sheets and index cards. Moreover, users could now make calls directly from the Notion app (rather than retyping or copying and pasting the number), reducing wasted time and potential errors.
Over the following year, we launched Logistics and Wellness committees to lead projects to continually improve the program. The committees meet a few times per year to determine priorities and share updates. We are now utilizing Notion’s project management features to organize our work. These features include the ability to create Kanban boards, build progress bars, and assign tasks to projects and projects to committees. We have already seen this help us achieve better focus during meetings and leave participants with specific actionable tasks.
Through built-in analytics, we are able to track view counts for the entire workspace and each individual page. Over the last 90 days, the platform was viewed 1,241 times. The platform also maintains full version history which allows us to track who is making edits and what changes are made. In the last month, 90 edits were made including the addition of new pages and database items, modification of existing content, and changing user permissions. The high level of active and passive engagement is encouraging to the viability of the platform.
Minimal training is needed to use the platform effectively. Incoming interns receive a one-hour onboarding session which is practical in nature (interns are given questions simulating common resident tasks and asked to use Notion to figure out how to achieve them). Following this, questions about application use are answered on an as-needed basis through our residency group chat or email.
Limitations and Future Directions
Our Notion instance is a work in progress and several improvements will be necessary to achieve our vision of a 'one-stop shop' for resident education and well-being.
While residents frequently update content on various service pages, it is difficult to maintain adherence to a standardized format. As everyone is responsible for maintaining the integrity of the platform, the burden of oversight falls to no singular individual. As such, we have not yet systematized a process to review existing information. Page bloat and content disorganization occur as content is added, but efforts to address these issues are currently being discussed.
We have not completely solved the issue of multiple platforms, though the total number of information sources is reduced. The resident schedule continues to be maintained on a Google sheet and capabilities to incorporate it into Notion are limited. Our program previously used a proprietary platform to host instructional videos for operations, and migration of these videos to Notion is in progress. Our goal is to make Notion a hub for resident education, where didactic content as well as operative videos can be easily accessed.
Fundamental questions remain surrounding data governance and access. We currently give all residents and faculty members complete edit access to democratize the information ecosystem. As a result, information is updated with much greater frequency, and these updates are immediately reflected to all users. Yet, this amount of access carries risks. While inadvertent edits are made (which can easily be seen and undone through version history), to this day, there have been no malicious edits that negatively impact patient care. While the decentralized model optimizes ease of editability, it does forgo a traditional hierarchical structure that previously existed.
In the past few years, collaboration applications such as Notion have flourished to facilitate asynchronous information sharing. Such platforms are addressing challenges that organizations have faced for years but have grown in complexity in the COVID era. We are using Notion to create a digital operating system for residency. We champion an approach that embraces technology and empowers each resident to take ownership of the collective knowledge of the program. Our vision is to have all the information of residency in the palm of your hand, in three clicks or less. While any technology has its limitations and raises new issues, we believe this platform can revolutionize the way our trainees access, interact with, and learn the information of residency.
Responses to Reviewers
Our paper was submitted for publication and rejected during the peer review process. We asked the journal if we could publish the reviewer comments and our responses but were denied permission. Instead, we will attempt to paraphrase the comments and our rebuttals here.
One reviewer felt that many programs had similar platforms in place. We did not find this to be true in our exploratory analysis. We conducted informal surveys and spoke to residents at national conferences. A majority of survey responses indicated that residents did not have centralized knowledge sharing platforms in place. Further, while some residents were using such platforms, they differed from ours because they were not directly editable in real-time. The reviewer also felt our paper constituted an advertisement of one software option. We want to emphasize that none of the authors received financial compensation from Notion or any other company in this space. Finally, we accept that there are many platforms that could be used to organize the institutional knowledge of residency. While we present one, we would be excited to hear about the experiences that other institutions have with other platforms and collaboratively work towards designing the best optimal technology stack to teach and train residents. For that reason, it is even more important that technologies like this are discussed in the academic literature.
Another reviewer brought up the reasonable criticism that we are attempting to create a technological solution to a cultural problem and questioned whether residents would actually use the platform. We added data on both platform viewership (1241 views over last 90 days) and number of edits made (90 in the last month) to the Implementation section.
Many people - including one of the reviewers and people we speak to at conferences - want to know who is in charge of updating the information and making sure it is correct. We have deliberately chosen a decentralized approach that gives residents autonomy to maintain information. Before we implemented Notion, there was no routine faculty review of paper-based guides. Ultimately, there is a trade-off between conducting an overview of every piece of information posted on the platform and keeping the platform up-to-date. We chose to focus on the latter. We are also introducing faculty onto the platform and giving them edit access so that they can make edits and provide whatever oversight they feel is necessary.
Our central hypothesis in creating this platform was that providing residents a technical solution to access and organize information would allow them to quickly develop working knowledge of rote tasks and protocols and spend more time learning how to take care of patients and operate. Certainly, future work will need to be done in order to understand whether we are successful. Today, we can confidently say we have built a user-friendly, fast system that is frequently used and updated.
None of the authors received financial compensation from Notion or have any disclosures relevant to this paper.