Web-based Tutorial on Electrocardiograms
Concept of Testing while Teaching
Drs. Michael E. Cheung, James F. Burke, and Paul K. Schick
Lankenau Medical Center and Drexel University College of Medicine
Grant Support
 Sharpe-Strumia Foundation
 Kitchen Cardiology Fund
Importance of Electrocardiograms (ECGs)
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A simple non-invasive diagnostic test
Indispensable for diagnosing heart attacks and other cardiac disorders.
Used to monitor patients: ambulances, emergency rooms, operating
rooms, and, and intensive care units.
It is critical that all physicians be well trained in interpreting ECGs.
Given the importance of ECGs, we developed a web-based tutorial for our
cardiology fellows.
Features of our Tutorial
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The tutorial quizzed participants and provided immediate feedback
It demanded an in-depth understanding of features of abnormal ECG
It was blended learning: complemented lectures and clinical experience
Our tutorial was the first to “test knowledge while teaching”
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Responses to questions were stored in a database
Stored answers were transferred to an Excel spreadsheet for analysis
Basic knowledge, fellow competence, and tutorial quality were assessed
You can view and use Our ECG tutorial
ecg.tutorialmed.com (URL)
You can use an anonymous name when signing in.
If you are not a physician, sign in as a medical student
Results of Post-Hoc Analysis: ECG Tutorial
Documented fellows’ ability to interpret ECGs.
Determined competency: One fellow required remediation
How fellows studied the tutorial. For example, the number of times fellows
restudied sections of the tutorial
4) Identified difficult ECGs
a) Some of these ECGs were of poor quality and replaced
b) Others ECGs were adequate. Hence, we placed more emphasis on
teaching these ECGs in our training program
5) Feedback assessed. Fellows were overwhelmingly positive about the value of
the tutorial. They felt that testing was not intimidating.
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The post-hoc analysis of “testing while educating” revealed weakness in our
training program, in a few trainees, and in the tutorial. Once revealed, we
were able to use this information to optimize our training program
Limitation: Small Sample Size
One limitation of the analysis of responses in the ECG tutorial was the small
sample size. Only 9 cardiology fellows participated.
Most medical fellowship programs have less that 10 fellows. Hence, sample
size can be a problem when studying fellows in any training program.
We would like to present our experience in previous studies in which we
had applied the concept of “testing during teaching” and post-hoc analysis
of answers.
Three previous studies in which “testing while
teaching” and post-hoc analysis were carried out
Subject
Trainees or Students
n
Mechanism
Bleeding disorders
Hematology Fellows
Medical Residents
13
Computer-based
tutorial
Hematology emergencies
Peripheral smears
Residents & Med Students
Residents & Med Students
32
24
ARS
ARS
Basic cardiology course
Cardiology Fellows
11
10 lectures (ARS)
First Study
Computer-based tutorial Bleeding Disorders Post hoc
analysis (Drexel & Lankenau)
Pathophysiology
Hematology
Fellows (n =6)
3 to 6 years after
medical school
74.6 +/- 9.7
Medical (n = 7)
Residents
1 to 3 years after
medical school
55.0 +/- 16.9
Choice of tests
52.8 +/- 10.8
36.1 +/- 14.5
Diagnosis
85.3 +/- 15.1
64.9 +/- 14.4
Management
54.6 +/- 11.4
37.6 +/- 18.3
Value of post hoc analysis:
 Demographic information: Differences in hematology fellows and medical
residents knowledge. Helped us target training for these groups.
 Weakness in choosing tests and management: Helped us improve our
training to spend more time teaching these subjects.
 Recorded time spent: Fellows 69 minutes; Residents 65 minutes. This
represented serious efforts.
Second Study
(Two Audience Response assisted
PowerPoint lectures)
1) Hematologic
Emergencies (n=32)
2) Normal and abnormal blood
cell morphology on peripheral
Smears (n=24)
Results presented in next slide
Two audience response assisted PowerPoint lectures.
Value of “Testing while teaching” & post-hoc analysis of answers
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Groups in the bar graph: PGY1 - post graduate year one of training after
medical school; PGY2 – post graduate year 2; PGY3 – post graduate year 3;
STUD – medical student
The bar graph (previous slide) shows that the ability to manage hematology
emergencies increases with medical training.
The Table shows the ability to interpret normal and abnormal peripheral
blood smears does not improve with training.
This information revealed a deficiency in our medical teaching. Residents
rely on the laboratory to interpret peripheral smears and do not interpret
blood cells in peripheral smears. Hence, their skills do not improve.
In contrast, residents are constantly involved in managing medical
emergencies, and therefore they improve their skills in handling hematologic
emergencies.
This information has helped us modify our training program to emphasize
the interpretation of normal and abnormal blood cells in peripheral smears.
Third Study
Cardiology essentials for cardiology fellows (10 lectures)
Audio response lectures & Post-Hoc Analysis of 1147 questions
Outstanding lectures (mean grade Poor lectures (mean grade – SD)
+ SD) 81% or more
65% or less
Cardiovascular physiology (84%) Physical Exam (65%)
Revascularization (82%)
Atrial septal defect (58%)
Mitral stenosis (83%)
Ventricular septal defect (65%)
Pericarditis (81%)
Congenital disorders I (56%)
Tetralogy of Fallot (84%)
Congenital disorders II (52%)
Value of post-hoc analysis
Outstanding and poor lectures were identified: This helped improve the
teaching of poor lectures and increase fellow experience with these disorders.
Two fellows needed remediation (grades > 1 SD below the mean grade)
Evaluation of lectures and questions: Eleven questions not graded since
found to be ambiguous or unfair.
Feedback
Lecture/tutorial
1 to 5 (1 is best)
Bleeding disorders (tutorial)
1.53
Hematology emergencies ARS
Peripheral smears (ARS)
1.45
1.58
Cardiology (ARS)
1.40
ECG interpretation (tutorial)
1.58
We were very pleased with the feedback from fellows. Any grade that
approaches 1.5 (1 is the best out of 5) indicates that fellows were very
satisfied. Also, they were not intimidated by having to answer questions
during lectures or when using a computer-based or web-based tutorials.
In the course on cardiology essentials , fellows were asked “were you
comfortable with our monitoring your knowledge“. Mean response was 1.6
“Testing while teaching”
Information from Post-Hoc Analysis
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Strengths and weaknesses in knowledge
Identified difficult topics
Detected fellows who needed remediation
Demographic information
Well-accepted and not threatening
Information used to optimize training programs
Testing basic knowledge while teaching
versus stand alone exams.
Advantages of testing while teaching & post hoc analysis over stand alone exams.
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Can be more comprehensive and cover core information (questions introduce
all topics and reflect the emphasis in tutorials and lectures. In the course of
Cardiology Essentials we asked 1147 questions.)
 Can evaluate quality of lectures and questions as well as knowledge.
 More efficient (avoids effort of preparing exams).
 Less anxiety: Focus is on education and not testing.
 Well accepted by trainees
“Testing while teaching” can be applied to all levels of education including K6 to k12
 The approach can be used instead of stand-alone testing required by the No Child Left
Behind Act (2001)
We are interesting in helping implement
the “testing while teaching” approach”.
 This educational approach can be applied to all levels of
education and training from K6 to K12 to graduate
programs.
 We use Microsoft Visual Studio to develop tutorials
The software is effective for educational apps
It is flexible and can easily manage images.
Data can be collected in an on-line database
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Possible assistance and collaboration:
 We could provide support by email or means of communication.
 We could collaborate and prepare tutorials using Microsoft Visual
Studio software for any educational endeavor.
 If interested, contact Paul K. Schick (pksone@comcast.net)