Staying Current Mechanisms in cardiovascular diseases: how useful are medical textbooks, eMedicine, and YouTube?
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DISCUSSION The aim of this study was to evaluate the usefulness of learning resources commonly used by students, including med- ical textbooks, eMedicine, and YouTube videos, on cardiovas- cular mechanisms, with particular emphasis on clarity, quality, and percentage of content committed to cardiovascular mecha- nisms. The author is not aware of any research in the literature addressing this area. A total of 65 chapters from 17 textbooks and 48 topics from eMedicine and 29 YouTube videos were included in this study. Most textbooks were brief in explaining mechanisms of cardiovascular diseases. Although the overall average committed to cardiovascular mechanisms in physiol- ogy textbooks (n ϭ 7) was 16.1% (99.5 of 618) and pathology textbooks (n ϭ 4) was 17.5% (64 of 364), there was less emphasis on mechanisms in most internal medicine textbooks (n ϭ 6), with a total average of 6.9% (79.7 of 1,150). Flow diagrams explaining mechanisms were also lacking. Although physiology textbooks allocated a higher percentage of content to mechanisms, the mechanisms in physiology books lacked details about pathological changes at organ and cellular levels. Furthermore, mechanisms in both physiology and pathology textbooks lacked integration of knowledge in relation to patient symptoms, clinical signs, and interpretation of investigation results. Such information will add a meaningful dimension to mechanisms. Unfortunately, internal medicine textbooks did not resolve this area of need and did not give mechanisms priority. Taking these findings together with the lack of flow diagrams explain mechanisms in these textbooks into consid- eration, it may be necessary, as per these results, that editors and publishers add flow diagrams explaining mechanisms and summarizing the pathophysiology of cardiovascular diseases. The percentage of figures committed to explaining cardiovas- cular mechanisms in physiology textbooks ranged from 7.2% (7 of 97) to 30% (9 of 30), in pathology textbooks from 5.2% (3 of 57) to 24% (12 of 50), and in internal medicine textbooks from 0.0% (0 of 3) to 9.7% (17 of 179). All internal medicine textbooks except Longo et al. (27) contained little information about cardiovascular mechanisms. Building mechanisms is a challenging process. For example, there is no definition on what constitutes an ideal mechanism, students usually find building mechanisms not an easy job, PBL tutors are usually not experts in the cases discussed, feel unable to facilitate the discussion of mechanisms, or provide feedback to students on what they have created in the tutorials, and both students and tutors do not know which learning resources they could turn to in regard to identifying and clarifying mechanisms (5). eMedicine topics discussed cardiovascular mechanisms ad- equately in 22.9% (11 of 48) of the topics, and the percentage of contents allocated to mechanisms in eMedicine topics was higher 15.8% (46.2 of 292) compared with that of any internal medicine textbook. Cardiovascular mechanisms were clearly outlined for a number of topics, including paroxysmal su- praventricular tachycardia, premature ventricular contraction, Staying Current 129 LEARNING RESOURCES AND MECHANISMS Advances in Physiology Education • doi:10.1152/advan.00149.2013 • http://advan.physiology.org by 10.220.33.2 on February 5, 2017 http://advan.physiology.org/ Downloaded from
Table 2. Summary of cardiovascular mechanisms in Medscape (eMedicine) topics Topic*
Pages on Mechanisms/ Pathophysiology Total
Pages† Percentage of Mechanism Number of Diagrams/ Tables Covering Mechanisms Content
Clarity Quality
Adequacy Comments (Reference) Atrial fibrillation 1 9 11.1 0 2 2 2 Atrial flutter 1 6 16.6 2 images and 1 ECG tracing
2 2 2 The mechanism given should be updated in light of current publications/research. Atrial tachycardia 1.5 7
0 3 3 2 Atrioventricular block 0.5 5
0 2 2 2 Atrioventricular dissociation 0.5 2
0 3 3 3 First-degree atrioventricular block 0.5 4
0 2 2 2 Long QT syndrome 2 7
1 table 3 3 3 Paroxysmal supraventricular tachycardia 3 8
ECG tracings 2 3 3 Premature ventricular contraction 0.5 2
0 3 3 3 Second-degree atrioventricular block 0.5 6
0 2 2 2 Sinus bradycardia 0.5 2
0 2 2 2 Sudden cardiac death 1 5
2 diagrams 2 2 2 Third-degree atrioventricular block 1.5 4
0 2 2 2 Ventricular fibrillation 0.5 7
0 2 2 2 Atrial tachycardia 0.5 10
0 2 2 2 Wolff-Parkinson-White syndrome 1.5 8
0 2 2 2 Coronary artery atherosclerosis 2 11
1 diagram 3 3 3 The mechanism was clearly explained. Hypertensive heart disease 0 16
0 1 1 1 The chapter focused on clinical issues and did not address mechanisms. Noncoronary atherosclerosis 1 7 14.2 0 1 1 1 Mentioned risk factors and did not address mechanisms. Renovascular hypertension 2.5 6
3 images 3 2 3 A diagram summarizing the mechanism would be much better.
Risk factors for coronary artery disease 0 7 0.0 1 flow diagram 1 1
The discussion focused on risk factors. The author did not explain the underlying mechanisms. Acute coronary syndrome 0 5 0.0 0 No mention of mechanisms. Angina pectoris 0.5
5 10 0 2 2 2 Coronary artery vasospasm 0.5
2 25 0 2 2 2 Myocardial infarction 1.5
10 15 0 A diagram linking risk factors with the mechanism of myocardial infarction is needed.
Unstable angina 2 8 25 0 2 2 2 A diagram summarizing mechanisms is needed. Alcoholic cardiomyopathy 0 7
0 No mechanism or pathophysiology is provided. Cardiogenic pulmonary edema 1 3
0 3 3 3 Cardiogenic shock 2 9
0 3 3 3 Cor pulmonale 1 8
0 2 2 2 Dilated cardiomyopathy 1 7
0 3 3 3 The mechanism is explained, but a diagram is needed to summarize the mechanism. Heart failure 3 11 27.2 0 3 3 3 The mechanism is well explained, but a diagram is needed to summarize the mechanism. Hypertrophic cardiomyopathy 0.5 5
0 1 1 1 The mechanism did not consider the genetic basis for hypertrophic cardiomyopathy. The mechanism did not discuss the molecular pathogenesis of hypertrophic cardiomyopathy and microvascular dysfunction. Restrictive cardiomyopathy 1 4
0 2 2 2 Acute pericarditis 1 9
0 2 2 2 Constrictive pericarditis 1 4
1 diagram 2 2 2 Pericardial effusion 0.5 6
0 2 2 2 Peripheral vascular disease 1 7
0 2 2 2 Aortic regurgitation 1 4
0 2 2 2 Incomplete. The mechanism given should be updated in light of current publications/research.
Staying Current 130 LEARNING RESOURCES AND MECHANISMS Advances in Physiology Education • doi:10.1152/advan.00149.2013 • http://advan.physiology.org by 10.220.33.2 on February 5, 2017 http://advan.physiology.org/ Downloaded from
cardiogenic pulmonary edema, cardiogenic shock, dilated car- diomyopathy, heart failure, long QT syndrome, and infective endocarditis. However, several topics lacked or had poorly provided mechanisms, such as hypertensive heart disease, noncoronary atherosclerosis, risk factors for coronary artery disease, hypertrophic cardiomyopathy, mitral regurgitation, mitral stenosis, mitral valve prolapse, pulmonary regurgitation, and rheumatic fever. More importantly, no flow diagrams or videos explaining mechanisms were included, and the topics were presented in a way similar to that of textbooks. As an online resource, eMedicine should effectively use the technical advantages available to online resource and include videos, educational multimedia programs, or interactive electronic tasks that can deepen the understanding of mechanisms at the body system, organ, cellular, and molecular levels, therefore adding new dimensions to the understanding of mechanisms (16). Vosky et al. (41), in an innovative study, examined the quality of internet information on pediatrics otolaryngology mainly in Wikipedia, eMedicine, and Medline Plus (41). They found that the content accuracy of eMedicine scored highest (84%, P Ͻ0.05) over Medline Plus (49%) and Wikipedia (46%). They concluded that eMedicine has the most accurate comprehensive contents and fewest errors but that the topics were challenging to read and navigate. The results from this study demonstrated that eMedicine cardiovascular topics allo- cated more contents to mechanisms than any of the internal medicine textbooks. However, topics varied in regard to ade- quacy of mechanisms, and the contents of several topics lacked clarity and quality of information. Despite the smaller number of educationally useful You- Tube videos identified (16 videos) and the fact that these videos focused on certain cardiovascular diseases, there is no doubt that the animations and use of diagrams in these videos Table 2.—Continued Topic* Pages on
Mechanisms/ Pathophysiology Total Pages†
Percentage of Mechanism Number of Diagrams/ Tables Covering Mechanisms Content
Clarity Quality
Adequacy Comments (Reference) Aortic stenosis 0.5
5 10 0 2 2 2 Infective endocarditis 2.5
11 22.7
0 3 3 3 The mechanism is well explained, but a diagram is needed to summarize the mechanism. Mitral regurgitation 0.5 4
0 1 1 1 Mitral stenosis 0.5 2
0 2 1 1 The underlying mechanism for pulmonary arteriolar constriction is not explained, nor is that hypoxic pulmonary vasoconstriction resides in pulmonary arterial smooth muscle cells. The pathogenesis of right-sided heart failure as the diseases progresses is not explained. Mitral valve prolapse 0.25 3
0 1 1 1 No mechanism was given. The authors discussed the natural history of mitral valve prolapse and myxomatous degeneration of collagen fibrils, etc. Primary pulmonary hypertension 1 4
0 2 2 2 Incomplete. The mechanism given should be updated in light of current publications/research. Pulmonary regurgitation 0.1 1
0 1 1 1 No mechanism given. The authors briefly discussed the causes of pulmonary regurgitation. Pulmonary stenosis 10.5 2
0 2 2 2 Incomplete. The mechanism given should be updated in light of current publications/research. Rheumatic fever 0.4 7
0 1 1 1 The mechanism did not discuss the pathogenic mechanisms of cross-reactive autoantibodies that target cells, cardiac valves in rheumatic heart disease, and neural cells in Sydenham chorea. *Not all cardiovascular topics shown on eMedicine were included in this evaluation. Topics that were too specialized and not needed at undergraduate level were not included. †Because of variability in the number of pages allocated to references, the list of references and information about the authors were not counted in the total number of pages. Staying Current 131
LEARNING RESOURCES AND MECHANISMS Advances in Physiology Education • doi:10.1152/advan.00149.2013 • http://advan.physiology.org by 10.220.33.2 on February 5, 2017 http://advan.physiology.org/ Downloaded from
added a unique feature to the understanding of mechanisms that can add to what is learned from textbooks and eMedicine articles. Videos are a medium that can transfer the motion through animations that can help learners to understand com- plex events (17) and the sequence of changes at the cellular and molecular levels. Being available free on the internet and easily accessible, YouTube videos have become a popular resource used by students (4, 11). The results from this study show that the total duration of useful videos was 340 min and 07 s and that the total number of viewers was 274,077, attracting 209,597 (76.4%) of all viewers, which indicates the interest of viewers in learning about cardiovascular mechanisms from YouTube videos. Reading textbooks and other resources such as eMedicine and review articles along with watching online videos has become a valuable learning strategy among medical students. Therefore, identifying educationally useful resources is essential to ensure quality learning from up to date and scientifically correct resources. Table 3. Details about YouTube videos discussing cardiovascular mechanisms identified in the study Number
Title URL
Duration Viewers
Days on YouTube
Viewership per Day
Total score* 1 Pathophysiology of Diastolic and Systolic CHF http://www.youtube.com/watch?v ϭOwvrBVw_J4Y 21 min 18 s 38,594 465
82.9 13.67
Ϯ 1.52 (12–15) 2 Congestive Heart Failure - Epidemiology and Pathophysiology (Part 1 of 3) http://youtu.be/t4e8ucPzRjQ 55 min 7 s 7,723 414
18.6 14.67
Ϯ 0.57 (14–15) 3 Recent insight into the pathophysiology of heart failure http://www.youtube.com/watch?v ϭFfPUaoyARtk 30 min 50 s 57 302
0.2 13.33
Ϯ 1.15 (12–14) 4 Pathophysiology of Coronary Artery Disease http://www.youtube.com/watch?v ϭpXluagz53kc 20 min 10 s 22,019 465
47.3 14.33
Ϯ 0.57 (14–15) 5 Pathophysiology of Atherosclerosis http://www.youtube.com/watch?v ϭrktoF7BHRiQ&listϭ PL4C480876D0558842 23 min 50 s 22,021 465
47.3 13.67
Ϯ 0.58 (13–14) 6 Pathophysiology of Wolff-Parkinson White Syndrome http://www.youtube.com/watch?v ϭ_cYThiC-0uk 12 min 37 s 5,052 465
10.8 13.67
Ϯ 0.57 (13–14) 7 Pathophysiology of Cardiac Arrhythmias http://www.youtube.com/watch?v ϭ_50jV3DKryQ&listϭ PL4C480876D0558842 20 min 48 s 15,000
464 32.3
13.67 Ϯ 0.57 (13–14) 8 Pathophysiology of Hypertensive Nephropathy http://www.youtube.com/watch?v ϭUTLCPpM2vZ8 16 min 41 s 6,421 448
14.3 14.33
Ϯ 0.57 (14–15) 9 Pathophysiology cardiovascular 1 of 5 Risk factors http://www.youtube.com/watch?v ϭXPzYkTjN4t4 46 min 22 s 44 60
14.00 Ϯ 1.00 (13–15) 10 Pathophysiology Cardiovascular 2 of 5 Peripheral artery disease http://www.youtube.com/watch?v ϭl3Pcoc3rzR4 28 min 56 s 56 183
0.3 14.33
Ϯ 0.57 (14–15) 11 Pathophysiology cardiovascular 3 of 5 heart disease http://www.youtube.com/watch?v ϭF35dTjjGy_Y 38 min 42 s 63 60
14.67 Ϯ 0.57 (14–15) 12 Pathophysiology of Pulmonary Arterial Hypertension (PAH) http://www.youtube.com/watch?v ϭ9a4untSzLzg 7 min 19 s 2,305 178
12.9 14.33
Ϯ 0.57 (14–15) 13 Pathogenesis of the Atherosclerotic Plaque and Acute Coronary Syn http://www.youtube.com/watch?v ϭupb37rbS1dE 3 min 45 s 26,614 536
49.6 14.33
Ϯ 0.57 (14–15) 14 Shotgun USMLE Renal Cardiac Pathophysiology 1 http://www.youtube.com/watch?v ϭ08QUa6_zRUs 8 min 57 s 155 690
0.22 12.33
Ϯ 1.15 (11–13) 15 Overview of Coronary Artery Disease http://youtu.be/NZ14XjOQoFY 2 min 58 s 22,242
840 26.4
14.33 Ϯ 0.58 (14–15) 16 Congestive Heart Failure Medical Animation http://www.youtube.com/watch?v ϭJJAMYHAwCMs 2 min 23 s 41,231 887
46.4 13.67
Ϯ 0.57 (13–14) 17 Coronary Artery Disease: Cause of Heart Attack - One Minute Medic
http://www.youtube.com/watch?v ϭLmzfiA1FA-E 1 min 33 s 1,439
155 9.2
8.33 Ϯ 0.57 (8–9) 18 Pathophysiology of CAD/MI Dr. Milind Hanchate http://www.youtube.com/watch?v ϭ_pOeefZN-Wc 24 min 22 s 26 107
0.24 6.67
Ϯ 1.52 (5–8) 19 ЉPathophysiologyЉ, Hypertension http://www.youtube.com/watch?v ϭ9FuSdiFRK3Y 5 min 4 s 106
19 5.5
6.67 Ϯ 1.15 (6–8) 20 Pathophysiology Љ, Mitral Valve Stenosis
http://www.youtube.com/watch?v ϭVVlJX-Fd_hI 4 min 18 s 43 49 08 5.33
Ϯ 1.15 (4–6) 21 Atherosclerosis (Understanding Disease: Cardiovascular Medicine) http://www.youtube.com/watch?v ϭ7JihvMpEP4w 2 min 48 s 36,288
628 57.7
8.67 Ϯ 0.57 (8–9) 22 How Hypertension Affects Cardiac Risk http://www.youtube.com/watch?v ϭjSrtyeXM59w 2 min 47 s 102 271
0.37 7.00
Ϯ 0.00 (7–7) 23 ЉPathophysiologyЉ, Myocardial Infarction http://www.youtube.com/watch?v ϭAquIpZVNc7w 2 min 36 s 340 193
1.7 5.67
Ϯ 1.15 (5–7) 24 Pathophysiology of heart failure http://www.youtube.com/watch?v ϭBmkARWsZJAk 3 min 14 s 158
43 3.6
3.33 Ϯ 0.58 (3–4) 25 ЉPathophysiologyЉ, Heart Failure http://www.youtube.com/watch?v ϭ_IPuJvxtwqo 7 min 12 s 27 28 0.9 6.00
Ϯ 1.00 (5–7) 26 Congestive Heart Failure http://www.youtube.com/watch?v ϭb2q672lG3Nk 6 min 12 s 20,073
1605 12.5
7.67 Ϯ 1.15 (7–9) 27 Pathophysiology Љ, Valvular Heart Disease
http://www.youtube.com/watch?v ϭ7r4LQtACr-s 1 min 45 s 411
190 2.1
5.67 Ϯ 1.15 (5–7) 28 Pathophysiology of Heart Failure http://www.youtube.com/watch?v ϭECpGxkinwXs 11 min 22 s 4,028
213 18.9
4.33 Ϯ 0.57 (4–5) 29 Hypertension and the Mechanism of Blood Pressure http://www.youtube.com/watch?v ϭsJop3D4YSr4 1 min 33 s 1,439 155
9.2 6.33
Ϯ 1.15 (5–7) Numbers 1–16 comprise educationally useful videos on cardiovascular mechanisms (n ϭ 16). Numbers 17–29 comprise noneducationally useful videos on cardiovascular mechanisms (n ϭ 13). *Total score [in means Ϯ SD (minimum–maximum)] was calculated from the scores given by the three evaluators to each video. CHF, congestive heart failure; USMLE, United States Medical Licensing Examination; CAD, coronary artery disease; MI, myocardial infarction. Staying Current 132
LEARNING RESOURCES AND MECHANISMS Advances in Physiology Education • doi:10.1152/advan.00149.2013 • http://advan.physiology.org by 10.220.33.2 on February 5, 2017 http://advan.physiology.org/ Downloaded from
The methods used in this study to assess the textbooks and eMedicine topics aimed at providing a critique of the clarity, quality, adequacy, and percentage of content committed to mechanisms. Three evaluators conducted the assessment of each of these learning resources independently, and the tools used were piloted before their implementation. The interrater agreement among the three evaluators was in the range of 0.55– 0.95 for the textbooks and eMedicine and in the range of 0.78 – 0.96 for the YouTube videos, indicating the reliability of the measures used (21, 32, 40, 43). The system used in the assessment of the YouTube videos is simple, easy to apply, and covers four key elements, namely, scientific content, technicality, authority, and pedagogy param- eters. The criteria system used in this study has shown its capacity to accommodate these four parameters, and the inter- rater agreement among assessors had scores in the range of 0.78 – 0.96. Piloting the use of the criteria before their imple- mentation to this project has helped in preparing the evaluators on applying the criterion system and, hence, the achievement of the high interrater scores of agreement. The small number of videos covering cardiovascular mech- anisms is a limitation to this study. However, the study was limited to videos in the English language and only those covering cardiovascular mechanisms or pathophysiology. These two factors could have possibly contributed to the small number of videos identified. The study was also limited to YouTube videos, and it is possible that there are other educa- tionally useful videos on other websites, such as those of medical professional societies and medical journals, that were not included. Based on this study, it is recommended that publishers and editors of undergraduate medical textbooks include mecha- nisms and flow diagrams outlining mechanisms and showing changes at the body system, organ, cellular, and molecular levels. In addition, authors and producers of digital resources should give more attention to mechanisms and pathophysio- logical changes of cardiovascular diseases. Innovative ideas that could enable learners to build mechanisms and integrate knowledge in an engaging and interactive way are recom- mended. Further research is needed to assess the impact of using learning resources demonstrating well-presented cardio- vascular mechanisms on students’ learning and the impact of using multimedia on cardiovascular mechanisms on students’ learning processes and the ability to integrate basic and clinical sciences as well as their clinical reasoning and decision- making skills. In conclusion, despite the importance of mechanisms in understanding cardiovascular diseases and in explaining the pathophysiological changes, integrating basic and clinical sci- ences as well as explaining symptoms and clinical signs and results of investigations, there was less emphasis on mecha- nisms in most internal medicine textbooks, and none of the textbooks used flow diagrams to outline mechanisms or ex- plained the pathogenesis/pathophysiology of cardiovascular diseases. Although the overall average percentage committed to cardiovascular mechanisms in physiology and pathology textbooks was higher than that in internal medicine textbooks, these textbooks limited the mechanisms at physiological or pathological aspects with no links to clinical symptoms, signs, or investigation results. eMedicine topics on cardiovascular diseases described mechanisms adequately for 22.9% (11 of 48) of the topics, and the percentage of content committed to mechanisms was higher than that of any internal medicine textbook. However, some topics did not have mechanisms. Educationally useful YouTube videos on cardiovascular mech- anisms, despite their small number, could add useful dimen- sions to the understanding of mechanisms at cellular and molecular levels. However, these videos focused on a few diseases. Such deficiencies in learning resources may add to the challenges faced by students enrolled in integrated and student self-regulated learning programs. Yüklə 89,82 Kb. Dostları ilə paylaş:
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