Implementation of a four-year multimedia computer curriculum in cardiology at six medical schools

MammographyOnline: An evaluation of an online mammography education program for radiographers

INTRODUCTION

In Australia, the gold standard for post graduate education in mammography is the Certificate of Clinical Proficiency in Mammography (CCPM) awarded by the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT). The award has two components -academic and clinical. This paper reports on the experiences of the first online offering of the academic component, MammographyOnline (MO), by BreastScreen Victoria, Australia. Online learning is well established in health professional education at all levels of learning, however evaluation is essential to ensure its effectiveness and inform future development.

METHODS

Consenting course participants completed module evaluations, and pre and post program evaluations. Course planners (n = 5) attended a 1-h focus group about the development process. Placement supervisors (n = 3) took part in a 30 min semi-structured telephone interview, identifying views of graduate performance. Survey data and rating scales were analysed descriptively. Qualitative data from surveys and interviews underwent content analysis.

RESULTS

Course participants found the content of MO to be beneficial but highlighted technical issues and suggested improvements for more interactive methods of delivery. Enablers to the program's development identified by course planners, included having experienced and knowledgeable staff on-board, appropriate project management processes, and management support. Challenges expressed by course planners included staffing for the duration of the project and the burden of time and finances, though all perceived they had produced a high quality, relevant and comprehensive online programme. Supervisors recognised that MO fulfilled the requirements of the academic component of the CCPM but did not supersede the need for the clinical component.

CONCLUSIONS

Despite numerous challenges associated with its development, the overwhelming view of learners, developers and supervisors was that MO is a high quality academic program of learning, that provides the theory to support and prepare radiographers for their future clinical practice. Some refinement of content, assessment tasks and technical features are required.

Computer model for the cardiovascular system: development of an e-learning tool for teaching of medical students

BACKGROUND

This study combined themes in cardiovascular modelling, clinical cardiology and e-learning to create an on-line environment that would assist undergraduate medical students in understanding key physiological and pathophysiological processes in the cardiovascular system.

METHODS

An interactive on-line environment was developed incorporating a lumped-parameter mathematical model of the human cardiovascular system. The model outputs were used to characterise the progression of key disease processes and allowed students to classify disease severity with the aim of improving their understanding of abnormal physiology in a clinical context. Access to the on-line environment was offered to students at all stages of undergraduate training as an adjunct to routine lectures and tutorials in cardiac pathophysiology. Student feedback was collected on this novel on-line material in the course of routine audits of teaching delivery.

RESULTS

Medical students, irrespective of their stage of undergraduate training, reported that they found the models and the environment interesting and a positive experience. After exposure to the environment, there was a statistically significant improvement in student performance on a series of 6 questions based on cardiovascular medicine, with a 33% and 22% increase in the number of questions answered correctly, p < 0.0001 and p < 0.001 respectively.

CONCLUSIONS

Considerable improvement was found in students' knowledge and understanding during assessment after exposure to the e-learning environment. Opportunities exist for development of similar environments in other fields of medicine, refinement of the existing environment and further engagement with student cohorts. This work combines some exciting and developing fields in medical education, but routine adoption of these types of tool will be possible only with the engagement of all stake-holders, from educationalists, clinicians, modellers to, most importantly, medical students.

Simulation-guided cardiac auscultation improves medical students' clinical skills: the Pavia pilot experience

Clinical evaluation is the cornerstone of any cardiac diagnosis, although excessive over-specialisation often leads students to disregard the value of clinical skills, and to overemphasize the approach to instrumental cardiac diagnosis. Time restraints, low availability of "typical" cardiac patients on whom to perform effective bedside teaching, patients' respect and the underscoring of the value of clinical skills all lead to a progressive decay in teaching. Simulation-guided cardiac auscultation may improve clinical training in medical students and residents. Harvey(©) is a mannequin encompassing more than 50 cardiac diagnoses that was designed and developed at the University of Miami (Florida, USA). One of the advantages of Harvey(©) simulation resides in the possibility of listening, comparing and discussing "real" murmurs. To objectively assess its teaching performance, the capability to identify five different cardiac diagnoses (atrial septal defect, normal young subject, mitral stenosis with tricuspid regurgitation, chronic mitral regurgitation, and pericarditis) out of more than 50 diagnostic possibilities was assessed in 523 III-year medical students (i.e. at the very beginning of their clinical experience), in 92 VI-year students, and in 42 residents before and after a formal 10-h teaching session with Harvey(©). None of them had previously experienced simulation-based cardiac auscultation in addition to formal lecturing (all three groups) and bedside teaching (VI-year students and residents). In order to assess the "persistence" of the acquired knowledge over time, the test was repeated after 3 years in 85 students, who did not repeat the formal 10-h teaching session with Harvey(©) after the III year. As expected, the overall response was poor in the "beginners" who correctly identified 11.0 % of the administered cardiac murmurs. After simulation-guided training, the ability to recognise the correct cardiac diagnoses was much better (72.0 %; p < 0.001 vs. baseline). Rather unexpectedly, before the tutorial, the performance of VI-year students and of residents was not significantly different from their III-year colleagues, since the two groups correctly identified 14.2 and 16.2 % of the diagnoses, respectively. After the tutorial, the VI-year students and the residents also improved their overall performance (to 73.1 and 76.1 %, respectively; p < 0.001 for both when compared to before the tutorial). The persistence of this capability after 3 years was remarkable, since the 85 students who repeated the test without any further exposure to the 10-h teaching session with Harvey(©) correctly identified 68.4 % of the possible cardiac diagnoses (p < 0.001 vs. baseline). These data underscore the importance of clinical training in order to improve auscultation skills in our academic setting, prompting to redesign teaching curricula. Simulation-based cardiac auscultation should be considered as the "missing link" between formal lecturing and bedside teaching of heart sounds and murmurs.

Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82

Over the past two decades, there has been an exponential and enthusiastic adoption of simulation in healthcare education internationally. Medicine has learned much from professions that have established programs in simulation for training, such as aviation, the military and space exploration. Increased demands on training hours, limited patient encounters, and a focus on patient safety have led to a new paradigm of education in healthcare that increasingly involves technology and innovative ways to provide a standardized curriculum. A robust body of literature is growing, seeking to answer the question of how best to use simulation in healthcare education. Building on the groundwork of the Best Evidence in Medical Education (BEME) Guide on the features of simulators that lead to effective learning, this current Guide provides practical guidance to aid educators in effectively using simulation for training. It is a selective review to describe best practices and illustrative case studies. This Guide is the second part of a two-part AMEE Guide on simulation in healthcare education. The first Guide focuses on building a simulation program, and discusses more operational topics such as types of simulators, simulation center structure and set-up, fidelity management, and scenario engineering, as well as faculty preparation. This Guide will focus on the educational principles that lead to effective learning, and include topics such as feedback and debriefing, deliberate practice, and curriculum integration - all central to simulation efficacy. The important subjects of mastery learning, range of difficulty, capturing clinical variation, and individualized learning are also examined. Finally, we discuss approaches to team training and suggest future directions. Each section follows a framework of background and definition, its importance to effective use of simulation, practical points with examples, and challenges generally encountered. Simulation-based healthcare education has great potential for use throughout the healthcare education continuum, from undergraduate to continuing education. It can also be used to train a variety of healthcare providers in different disciplines from novices to experts. This Guide aims to equip healthcare educators with the tools to use this learning modality to its full capability.

Effective e-learning for health professionals and students-barriers and their solutions. A systematic review of the literature-findings from the HeXL project

INTRODUCTION

In 2003/4 the Information Management Research Institute, Northumbria University, conducted a research project to identify the barriers to e-learning for health professionals and students. The project also established possible ways to overcome these barriers. The North of England Workforce Development Confederation funded the project.

METHODOLOGY

The project comprised a systematic review of the literature on barriers to and solutions/critical success factors for e-learning in the health field. Fifty-seven references were suitable for analysis. This review was supplemented by a questionnaire survey of learners and an interview study of learning providers to ensure that data identified from the literature were grounded in reality.

RESULTS

The main barriers are: requirement for change; costs; poorly designed packages; inadequate technology; lack of skills; need for a component of face-to-face teaching; time intensive nature of e-learning; computer anxiety. A range of solutions can solve these barriers. The main solutions are: standardization; strategies; funding; integration of e-learning into the curriculum; blended teaching; user friendly packages; access to technology; skills training; support; employers paying e-learning costs; dedicated work time for e-learning.

CONCLUSIONS

The authors argue that librarians can play an important role in e-learning: providing support and support materials; teaching information skills; managing and providing access to online information resources; producing their own e-learning packages; assisting in the development of other packages.

Active learning in a Year 2 pathology curriculum

PURPOSE

Team-based learning (TBL) has been successfully used in non-medical curricula, but its effectiveness in medical education has not been studied extensively. We evaluated the impact of TBL on the academic performance of Year 2 medical students at Wright State University by comparing this active learning strategy against a traditional method of case-based group discussion (CBGD).

METHODS

A prospective crossover design assigned 83 Year 2 medical students to either CBGD or TBL for 8 pathology modules in the systems-based curriculum. The effectiveness of both learning methods was assessed by performance on pathology-based examination questions contained in end-of-course examinations. The highest and lowest academic quartiles of students were evaluated separately. Students' opinions of both methods were surveyed.

RESULTS

No significant differences in whole group performance on pathology-based examination questions were observed as a consequence of experiencing TBL versus CBGD. However, students in the lowest academic quartile showed better examination performance after experiencing TBL than CBGD in 4 of 8 modules (P = 0.035). Students perceived that the contributions of peers to learning were more helpful during TBL than CBGD (P = 0.003).

CONCLUSION

This study demonstrates that TBL and CBGD are equally effective active learning strategies when employed in a systems-based pre-clinical pathology curriculum, but students with lower academic performance may benefit more from TBL than CBGD.

Shoestring budgets, band-AIDS, and team work: challenges and motivators in the development of a Web-based resource for undergraduate clinical skills teaching

Background

Learning how to conduct a medical interview and perform a physical examination is fundamental to the practice of medicine; however, when this project began, the methods used to teach these skills to medical students at the University of Toronto (U of T) had not changed significantly since the early 1990s despite increasing outpatient care, shorter hospital stays, and heavy preceptor workloads. In response, a Web-based clinical skills resource was developed for the first-year undergraduate medical course—The Art and Science of Clinical Medicine I (ASCM I).

Objectives

This paper examines our experiences with the development of the ASCM I website and details the challenges and motivators inherent in the production of a Web-based, multimedia medical education tool at a large Canadian medical school.

Methods

Interviews and a focus group were conducted with the development team to discover the factors that positively and negatively affected the development process.

Results

Motivating factors included team attributes such as strong leadership and judicious use of medical students and faculty volunteers as developers. Other motivators included a growing lack of instructional equivalency across diverse clinical teaching sites and financial and resource support by the Faculty of Medicine. Barriers to development included an administrative environment that did not yet fully incorporate information technology into its teaching vision and framework, a lack of academic incentive for faculty participation, and inadequate technical support, space, and equipment.

Conclusions

The success of electronic educational resources such as the ASCM I website has caused a significant cultural shift within the Faculty of Medicine, resulting in the provision of more space, resources, and support for IT endeavours in the undergraduate medical curriculum.

Use of hand-carried ultrasound devices to augment the accuracy of medical student bedside cardiac diagnoses

BACKGROUND

Hand-carried ultrasound (HCU) devices used by cardiologists as extensions of the physical examination have been shown to improve the accuracy of bedside diagnoses. We tested the feasibility of teaching medical students to use HCU devices to make bedside cardiac diagnoses and compared the accuracy of their HCU and physical examinations.

METHODS

In all, 10 fourth-year medical students enrolled in a 4-week medical school course on the cardiac examination. Students examined 12 standardized patients at 3 different time intervals: (1) on day 1 of the course; (2) on day 10 after review of cardiac physical examination using traditional teaching methods; and (3) after instruction on the use of HCU devices. Students were scored at each time interval for primary findings (most salient) and all findings, accounting for both errors of commission and omission. Scores could range from +12 to -12 for primary findings and from +22 to -22 for all findings. A perfect score was +12 for primary findings and +22 for all findings.

RESULTS

The average score for all students at baseline was -3.2 +/- 3.1 and -5.7 +/- 4.8 for primary and all findings, respectively. A significant improvement in the scores was noted with use of the HCU device (2.6 +/- 3.1 and 5.2 +/- 6.6 for primary and all findings, respectively) compared with the baseline and two subsequent physical examinations.

CONCLUSION

Instruction of fourth-year medical students on the use of HCU device is feasible and results in significantly more accurate bedside diagnoses.

Intelligent training system integrated in an echocardiography simulator

Computer simulators play an important role in medical education. We have extended our simulator EchoComJ with an intelligent training system (ITS) to support trainees adjusting echocardiographic standard views. EchoComJ is an augmented reality application that combines real three-dimensional ultrasound data with a virtual heart model enabling one to simulate an echocardiographic examination. The ITS analyzes the image planes according to their position, orientation and the visualization of anatomical landmarks using fuzzy rules. An adaptive feedback is provided that colors the specific anatomic landmarks within the contours of the virtual model based on the quality of the image plane.

Assessment of web-based applications for ambulatory care rotations

BACKGROUND

An interactive Web site was developed to supplement ambulatory care clinical rotations, optimize collaborative efforts of ambulatory care preceptors, and standardize the educational and evaluation experience.

OBJECTIVE

To evaluate perceptions of residents and students using an interactive Web site for ambulatory care clinical pharmacy rotations.

METHODS

An online anonymous survey comprised of 12 questions using a 5-point Likert scale (1-5, strongly disagree-strongly agree) and 4 open-ended questions was designed. Over a 3-year time frame, each student and resident rotating through the ambulatory care clinical rotation was instructed to complete the survey at the end of the rotation experience. Survey results were compiled and analyzed.

RESULTS

Sixty-nine percent (18/26) of residents and 71% (54/76) of students completed the survey. Overall, the Web site was well accepted by all learners. Residents and students differed in opinion on a few aspects of the Web site; however, both appreciated the ease of accessibility and links to additional resources. Inoperable links and outdated quizzes were identified as major weaknesses.

CONCLUSIONS

Perceptions of an interactive Web site used during ambulatory care clinical rotations were positive. The survey results reinforce the continued use of this teaching method and will enable preceptors to make appropriate adjustments for future learners.

The paediatrician and cardiac auscultation

The cardiac auscultation (CA) skills of paediatric residents and office-based paediatricians have recently been shown to be suboptimal. CA is known to have a high degree of specificity and sensitivity, and is inexpensive. New teaching aids and availability of surrogate patient heart sounds and murmurs now allow most physicians to acquire CA skills. These teaching aids should be available in all medical schools and in all postgraduate paediatric training programs. While the relationship between musicality and CA skill has not been proven, the author assumes this relationship to be valid. Specific learning objectives in CA should be established. Recognizing that the current trend is away from clinical examinations, students frequently are unaware that a CA learning deficit exists. Therefore, students' CA skills should be evaluated before medical school graduation and at the Royal College of Physicians and Surgeons specialty examination. Students with amusia (inability to distinguish pitch of sound) should be identified and consideration should be given to directing them away from a clinical specialty in which CA is important. Further study is required in the physiology of learning of CA. Appropriate action by medical school and paediatric postgraduate program directors and the Royal College will effect a higher standard of patient care by increasing CA skills, resulting in a more financially efficient system - something everyone is trying to achieve in these times of increasing medical care costs.

Adoption and integration of simulation-based learning technologies into the curriculum of a UK Undergraduate Education Programme

CONTEXT

At a time of significant changes in medical education world-wide, the international dimensions and global issues relating to the application of new learning technologies have been recognised.

OBJECTIVE

The aim of this paper is to describe the adoption and integration within the curriculum in one United Kingdom (UK) medical school of 'Harvey', the Cardiology Patient Simulator, and the UMedic multimedia computer-based cardiology curriculum - resources developed in a medical school in the USA.

PARTICIPANTS

The integration of the resources into the curriculum is described by 3 teachers actively involved in the cardiology curriculum of the UK medical school and 3 teachers associated with the development of resources in the USA. ASPECTS CONSIDERED: The review considers the adoption of Harvey and UMedic in the UK in programmes in relation to: curricular issues, training needs, learning outcomes, curriculum content and sequences of content, educational strategies, teaching and learning methods, assessment, communication about the curriculum and management of the curriculum.

CONCLUSIONS

Learning resources, in the form of simulators and computer-based learning modules, developed in one country can be successfully adopted and implemented in another. Facets that facilitated the adoption included close liaison between the developers of the resources in the USA and the implementers in the UK, and careful and systematic planning including in-depth integration of the simulation-based resources into the required curriculum rather than their relegation to a peripheral ad hoc position. The successful use of simulators such as Harvey requires the presence of a 'champion', a clinician educator and a supporting administrative staff who ensure the simulator's appropriate use.

The hand-carried echocardiographic device as an aid to the physical examination

Physical examination skills have been declining over the past several decades while technology has made diagnostic testing increasingly sophisticated. For patients with cardiovascular disease, the best approach to bedside diagnosis would be one that combines both physical examination and ready access to technology at the time of the patient encounter. Most cardiac testing is not performed at the bedside due to equipment size and time limitations for these tests. Small hand-carried echocardiographic devices are now available for rapid bedside examination. These devices compare well to full-featured systems when used in cardiology outpatient settings and in hospitalized patients who are not critically ill. Compared with physical examination by board certified cardiologists, these devices decrease diagnostic error. Early use of hand-carried echocardiographic devices after physical examination has been demonstrated to impact patient triage and treatment as well as uncover otherwise undetected cardiac disease. The degree of training required for responsible use of these devices is as yet unclear. However, organized training sessions have resulted in modest agreement with standard echocardiography and point-of-care echocardiography performed by expert echocardiographers. It is conceivable that the hand-carried echocardiographic devices will be used in medical school curriculum to enhance medical student education in the future.

Effectiveness of a cardiology review course for internal medicine residents using simulation technology and deliberate practice

BACKGROUND

Objective evaluations of residents' clinical skills reveal serious deficits.

PURPOSE

To develop, implement, and evaluate outcomes from a review course in cardiology bedside skills for internal medicine residents.

METHODS

We used a 1-group pretest-posttest design with historical comparisons. The study was conducted at the University of Miami School of Medicine as part of the internal medicine residency program from July 1999 to June 2000. A total of 67 2nd- and 3rd-year medicine residents received an educational intervention involving deliberate practice using simulation technology. A total of 155 4th-year medical students in one intervention and one comparison group (n = 53) served as historical comparisons. Outcome measures were a reliable computer-delivered pretest and posttest that evaluate cardiology bedside skills.

RESULTS

Residents who received the review course and medical students who received a comparable educational intervention showed large and statistically significant pretest-to-posttest improvement in bedside skills. These 2 groups are also significantly and substantially different at posttest from a comparison group of 4th-year medical students that did not receive a specific educational intervention.

CONCLUSION

Educational interventions using simulation technology that engage learners in deliberate practice of clinical skills produce large improvements in a relatively short time, with little faculty involvement.

Helping family physicians improve their cardiac auscultation skills with an interactive CD-ROM

INTRODUCTION

There have been few studies of the cardiac auscultation skills of residents and family physicians. This study assessed a group of family physicians' cardiac auscultation skills and use of a computerized self-instructional program to improve these skills.

METHODS

Forty-two volunteer family physicians participated in an initial assessment of cardiac auscultation skills using test recordings of 12 common heart sounds. They were provided with a CD-ROM instructional program and were asked to devote 15 hours of self-study to the program and to return in 9 months for reassessment.

RESULTS

The 42 family physicians in the initial assessment identified 39% of the heart sounds. Twenty-one returned for reassessment and showed significant improvement. Their initial mean score was 4.3 of 12 (35%), and their final mean score was 8.0 of 12 (67%). They found the CD-ROM program to be a valuable resource. The feature most liked was the unlimited opportunity to review sounds, cases, and tutorials. Most frequent problems related to computer access or skills. Eleven respondents reported using the program to resolve patient problems in their clinical practices.

DISCUSSION

The cardiac auscultation skills of a group of volunteer family physicians showed low initial scores that improved significantly after self-study with a CD-ROM instructional program. The program was a valuable self-instructional aid, and physicians used it as a resource in clinical practice. However, only 50% of the initial group completed the self-study and returned for final assessment. Providing more support and assistance in the initial phase, especially with computer use, may enable completion of similar computerized self-study programs.

Using a multimedia tool to improve cardiac auscultation knowledge and skills

OBJECTIVE

Today's medical school graduates have significant deficits in physical examination skills. Medical educators have been searching for methods to effectively teach and maintain these skills in students. The objective of this study was to determine if an auscultation curriculum centered on a portable multimedia CD-ROM was effective in producing and maintaining significant gains in cardiac auscultatory skills.

DESIGN

Controlled cohort study.

PARTICIPANTS

All 168 third-year medical students at 1 medical school in an academic medical center.

INTERVENTIONS

Students were tested before and after exposure to 1 or more elements of the auscultation curriculum: teaching on ward/clinic rotations, CD-ROM comprehensive cases with follow-up seminars, and a CD-ROM 20-case miniseries. The primary outcome measures were student performance on a 10-item test of auscultation skill (listening and identifying heart sound characteristics) and a 30-item test of auscultation knowledge (factual questions about auscultation). A subset of students was tested for attenuation effects 9 or 12 months after the intervention.

RESULTS

Compared with the control group (1 month clinical rotation alone), students who were also exposed to the CD-ROM 20-case miniseries had significant improvements in auscultation skills scores (P < .05), but not knowledge. Additional months of clerkship, comprehensive CD-ROM cases, and follow-up seminars increased auscultation knowledge beyond the miniseries alone (P < .05), but did not further improve auscultation skills. Students' auscultation knowledge diminished one year after the intervention, but auscultation skills did not.

CONCLUSION

In addition to the standard curriculum of ward and conference teaching, portable multimedia tools may help improve quality of physical examination skills.

Prehospital and hospital-based health care providers' experience with a human patient simulator

OBJECTIVES

To ascertain the level of acceptance of a human patient simulator as a training tool among a diverse group of health care providers. Secondary objectives were to elucidate its most useful aspects for training and find ways to improve upon the simulation experience.

METHODS

A satisfaction survey was conducted regarding the use of a human patient simulator from July 1999 to February 2000. The survey consisted of five questions with a five-point Likert scale (5 being the most favorable score) and three questions that asked for qualitative written feedback on the simulator experience. The survey was handed to 78 consecutive participants immediately after their experiences and collected immediately after it was filled out to ensure a 100% response rate to the overall survey. Qualitative responses were placed into categories by theme, and a sum was calculated for each category.

RESULTS

There was a high level of acceptance for simulation training among this diverse group, with Likert scores for the first two questions regarding general satisfaction of 4.74 +/- 0.126 (n = 77) and 4.77 +/- 0.126 (n = 78). Regarding the usefulness of each specific area of simulator training, the scores were 4.53 +/- 0.153 (n = 78) for patient assessment, 4.55 +/- 0.182 (n = 47) for treatment options, and 4.70 +/- 0.125 (n = 63) for response to treatment. There were 49 positive comments and nine negative comments. Realism (n = 26) and the ability to see response to treatment (n = 12) were the two most common positive comments. Negative comments focused on logistics of the simulator lab (n = 4) rather than the simulator itself.

CONCLUSIONS

In this sample, prehospital and hospital-based health professionals were accepting of human patient simulation as a new teaching tool with multiple useful applications.