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Archives of cardiovascular diseases
Volume 108, n° 8-9
pages 420-427 (août 2015)
Doi : 10.1016/j.acvd.2015.03.001
Received : 25 November 2014 ;  accepted : 3 Mars 2015
Cross analysis of knowledge and learning methods followed by French residents in cardiology
Analyse croisée des connaissances et des méthodes d’apprentissages des internes et assistants français en cardiologie
 

Aymeric Menet a, Nathalie Assez b, Dominique Lacroix a, c,
a Department of Cardiology, CHU de Lille, 59037 Lille cedex, France 
b Department of Emergency Medicine, CHU de Lille, 59037 Lille cedex, France 
c Faculty of Medicine, université Lille-2, 59000 Lille, France 

Corresponding author. Department of Cardiology, hôpital cardiologique, boulevard du Pr-Leclerc, 59037 Lille cedex, France.
Summary
Background

No scientific assessment of the theoretical teaching of cardiology in France is available.

Aim

To analyse the impact of the available teaching modalities on the theoretical knowledge of French residents in cardiology.

Methods

Electronic questionnaires were returned by 283 residents. In the first part, an inventory of the teaching/learning methods was taken, using 21 questions (Yes/No format). The second part was a knowledge test, comprising 15 multiple-choice questions, exploring the core curriculum.

Results

Of the 21 variables tested, four emerged as independent predictors of the score obtained in the knowledge test: access to self-assessment (P =0.0093); access to teaching methods other than lectures (P =0.036); systematic discussion about clinical decisions (P =0.013); and the opportunity to prepare and give lectures (P =0.039). The fifth variable was seniority in residency (P =0.0003). Each item of the knowledge test was analysed independently: the score was higher when teaching the item was driven by reading guidelines and was lower if the item had not been covered by the programme (P <0.001). Finally, 91% of students would find it useful to have a national source for each topic of the curriculum; 76% of them would often connect to an e-learning platform if available.

Conclusions

It is necessary to rethink teaching in cardiology by involving students in the training, by using teaching methods other than lectures and by facilitating access to self-assessment. The use of digital tools may be a particularly effective approach.

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Résumé
Contexte

Aucune évaluation scientifique de l’enseignement théorique de la cardiologie en France n’est disponible.

Objectif

Notre but était d’analyser l’impact des méthodes d’enseignement sur les connaissances théoriques des internes et assistants en cardiologie.

Méthodes

Deux cent quatre-vingt-trois internes et assistants ont répondu à un questionnaire électronique envoyé à l’ensemble des internes et résidents français. La première partie était un inventaire des différentes méthodes d’enseignement sous la forme de 21 questions Oui/Non. La seconde partie était une évaluation des connaissances théoriques sous la forme de 15 questions à choix multiples couvrant l’ensemble du programme.

Résultats

Parmi les 21 variables testées, 4 sont ressorties comme étant associées au score obtenu à l’évaluation des connaissances : l’accès à une auto-évaluation (p =0,0093), l’accès à d’autres méthodes pédagogiques que les cours magistraux (p =0,036), la discussion systématique avec un senior des décisions cliniques (p =0,013) et la possibilité pour les internes de préparer et donner eux-mêmes les cours théoriques (p =0,039). La cinquième variable était l’ancienneté (p =0,0003). Pour chaque QCM pris indépendamment, la note est plus élevée si l’information est tirée des recommandations et plus basse si aucune formation n’a été dispensée sur l’item testé par le QCM (p <0,001). Enfin, 91 % des étudiants trouveraient utile d’avoir une référence nationale pour chaque item du programme ; 76 % se connecteraient souvent à une plateforme de e-learning si elle était disponible.

Conclusions

Il est nécessaire de repenser l’enseignement en cardiologie en impliquant les étudiants dans l’enseignement, en utilisant des méthodes pédagogiques différentes du cours magistral et en facilitant l’accès à l’auto-évaluation. L’outil numérique semble être une approche adaptée à cet effet.

The full text of this article is available in PDF format.

Keywords : Training, Cardiology, Self-assessment, Distance learning, Residency

Mots clés : Enseignement, Cardiologie, Auto-évaluation, E-learning, Internes

Abbreviations : CI, MCQ, OR


Background

The digital revolution leads us to rethink medical education. Diversification of educational facilities and new technologies are already part of the educational arsenal in the world's largest universities. Technological innovations in e-learning help to individualize education (adaptive learning) and improve student/student and student/teacher interactions (collaborative learning). The European Society of Cardiology is currently involved in developing an extensive training programme integrating self-assessment modules [1].

It is intuitive to think that a medical doctor's knowledge is one of the major determinants of quality of care. Thus, the scientific community has a duty to provide evidence-based education to medical residents, as it is currently the standard for medication evaluation.

In France, after the first 6 years of medical school, students have a national examination. According to their ranking, students can choose their specialization. The cardiology residency lasts for 4 years and consists of eight 6-month internships: four in various subspecialties of cardiology; one in vascular medicine or surgery; and three outside the discipline (preferably in internal medicine and intensive care). Conforming to the regulations, the courses represent 250hours of training, which take place during the 4 years of residency. An exit examination is not needed, but a programme with the educational objectives is offered to students and teachers. The theoretical training of specialized medical residents is based mainly on local, regional or national lectures. Education at the regional level is based on clusters of three to six neighbouring universities, called ‘inter-regional areas’. In these areas, residents share lectures, workshops or seminars on a regular basis. National seminars consist of organized meetings for residents in cardiology, during which a major cardiology theme is approached tackled either by a lecture or by a more interactive approach. As showed in unpublished surveys by Moubarak et al., on behalf of the Group of Young Cardiologists appointed by the French Society of Cardiology, satisfaction with education remains low, at around 25–40%.

In this context, the assessment of the impact of teaching methods on residents’ expertise is a prerequisite for the evolution of medical education. We are therefore committed to understanding how residents have been trained since 2007, and to assessing the effect of each of these learning methods on residents’ knowledge.

Methods
Study population

A total of 780 electronic questionnaires were sent in June 2013 to residents and assistants affiliated to the French Society of Cardiology. Questionnaires were sent to all 28 French universities. Fifty email addresses were not functional. The electronic questionnaires were anonymous and were built using the ‘Google forms’ open source and secure software.

Composition of the questionnaire

The questionnaire consisted of two parts: an assessment of teaching methods followed by a knowledge test.

First part

Questions regarding teaching methods and satisfaction are summarized in Table 1. Ten Yes/No questions described the implicit or explicit theoretical academic organization of their curriculum. Ten Yes/No questions described the context of the education, as well as the personal and studying resources used. Three scales from 1 to 10 assessed residents’ feelings about theoretical education, practical (bedside) education, and the usefulness of the available educational resources on the web. The use of Likert scale questions, multiple-choice questions (MCQs) and the opportunity to give suggestions allowed the residents to communicate the reasons for their dissatisfaction.

Second part

The knowledge test consisted of 15 MCQs: three on heart failure; three on rhythm disturbances; two in the field of coronary artery disease; two on valve diseases; one on hypertension; one on pharmacology; one on cardiac physiology; one on sports cardiology; and the last one on internal medicine. The MCQs were initially graded out of 138 points but were subsequently scored out of 100 points. These MCQs are briefly described in Table 2 and detailed in a Appendix A. The knowledge test was designed by several subspecialists from Lille University Hospital and the quality of the answers to the MCQs was confirmed both in the literature and by experts.

For each of the 15 MCQs, students were asked to comment on where or how they had got the information that allowed them to answer to the question. Seven choices were possible: ‘the information to answer the MCQ was learned through: (1) experience and daily practice; (2) conferences; (3) lectures; (4) discussions with colleagues; (5) personal references; or (6) taken from international guidelines’; it was also possible for the individual to indicate that (7) they had followed no theoretical training regarding this item.

Statistical analysis

Continuous variables are expressed as means±standard deviations; categorical variables are expressed as frequencies and proportions. Comparison of the means of the scores obtained in the knowledge test was carried out using a two-sided Student's t test or the Mann-Whitney test. Correlation between satisfaction scores regarding practical and theoretical training was carried out using Pearson's correlation. The scores obtained in the knowledge test were studied separately with linear regression models and satisfaction was studied with logistic regression. A variable was concluded to be a prognostic factor if the level of significance of the variable was ≤0.05. A two-tailed P -value <0.05 was required for statistical significance. Statistical analysis was performed using SAS Enterprise Guide for Windows, version 6.1 (SAS Institute, Inc., Cary, NC, USA).

Results
Study population

Two hundred and ninety-seven residents returned the questionnaire; 283 of them completed it fully. All French universities were represented, except Saint-Etienne University. Response rates across the country are shown in Figure 1. The response rate by inter-regional area was relatively homogeneous (between 30 and 45%), except for the North-West region (the area of the initiator of the study), which had a higher participation rate (58%). People who started their residency in 2008, 2009, 2010 and 2011 were the most represented, with a 50% response rate, followed by students who started their residency in 2007 and 2012, with a 30–40% response rate, and, finally, students who started their residency in 2005 and 2006, with response rates of 5 and 15%, respectively.



Figure 1


Figure 1. 

A. Response rate by inter-regional areas. France is divided into seven areas, each representing a community of three to six universities. Reunion Island is joined to the South-West area (circle connected to the South-West area). Regions are: West, North-West, North-East, Paris area, South-West, Rhone-Alpes-Auvergne and South-East. B. Breakdown of response as a function of seniority. SD: year of study for cardiology-specialized diploma; CR: chief resident.

Zoom

Table 1 summarizes results regarding learning methods and satisfaction with theoretical training.

Knowledge test

The average score obtained in the knowledge test was 53/100, with a standard deviation of 8.5 points. The minimum and maximum scores were 29 points and 76 points, respectively. The effects of each of the educational methods on the score obtained in the knowledge test were tested by univariate analysis and are shown in Table 3. The results of linear regression of the knowledge score are shown in Table 4. The model includes all variables presented in Table 3.

A student with >3 years of experience got, on average, 4.2/100 points more than a younger resident (Table 4). The variable ‘access to self-assessment at least once every 6 months’ increased the score by 3.8/100 points. The variable ‘systematic discussions with senior doctors about problematic decisions’ gained 3.8/100 points. Finally, the variables ‘use of other teaching methods’ and ‘courses prepared by residents rather than senior doctors’ allowed residents to earn 3.1/100 and 2.3/100 points, respectively.

A cumulative effect of the use of various educational methods was observed in the determination of the score obtained in the knowledge test; results are shown in Figure 2.



Figure 2


Figure 2. 

Cumulative effect on the ‘baseline’ score, from left to right, of adding educational methods (the four educational methods that stood out in the multivariable analysis plus seniority). Circles represent outlier observations.

Zoom

For each item of the knowledge test taken independently, the score was higher if training was based on European Society of Cardiology guidelines, and lower if the student had not received any formal education on the said item (P <0.001). Among residents who had completed their 4 years of education, 17% of the items were declared as not having been formally taught during their residency.

Satisfaction and its determinants

Satisfaction with theoretical training was low and was considered less than satisfactory with regard to practical training (4.3/10±2 versus 6.3/10±2.2; P <0.001). Satisfaction varied from one university hospital to another; scores ranged from 2.2–6.7 out of 10 points.

There was a correlation between satisfaction scores about practical and theoretical training (r =0. 409; P <0.001). Variables predicting satisfaction about theoretical training were ‘frequent lectures’ (odds ratio [OR]=4.7), ‘other teaching methods’ (OR=3), participation in ‘national seminars’ (OR=2.1) and ‘in my education, I feel active’ (OR=3.5), whereas the variable ‘supplementary medical diplomas >2′ was associated with dissatisfaction (OR=0.5). Other variables were not significantly associated with satisfaction in the multivariable analysis.

In addition, 91 and 93% of students found it useful or very useful to have a national source and e-lectures online for each topic of the curriculum, respectively. Seventy-six percent of students would often or very often connect to an e-learning platform if available (0% of students would never connect); 66% of students would find it useful or very useful to have the opportunity for online self-assessment.

Discussion

The ubiquity of new technologies in our daily lives raises two issues: their development in teaching methods and their usefulness in the educational arsenal. The fact that this study includes both a description of learning methods and a knowledge assessment permits us to answer these questions.

Teaching by a senior doctor during rounds has always been the primary teaching method in France. This traditional way of teaching progressively gives the opportunity for frequent or systematic discussions in case of problematic decisions or for staff meetings. Lectures in the form of inter-regional seminars are increasing in importance compared with courses offered within the local or academic hospital. Senior doctors gradually give way to residents for course preparation. Finally, we see the emergence of new modes of giving lectures and new types of knowledge assessment, such as self-assessment.

The evolution of satisfaction about theoretical training can be seen in the 2007, 2010 and 2013 questionnaires launched by the French Society of Cardiology. Satisfaction remains low and relatively stable: the 2007 survey showed that 25% of students were satisfied or very satisfied compared with 40% in 2010. In 2013, the evaluation was based on a 10-point scale and the average was 4.3±2 points.

Is this a favourable evolution for instruction? The five teaching methods that emerged from the multivariable analysis as increasing the scores on the knowledge test (Figure 2) seem to support the current trends in education. Literature validates some of these results. Access to self-assessment has already been proven to be one of the most effective learning methods [2]. The Cone of Experience by Edgar Dale allows us to understand the need to involve other instruction methods [3], although scientific sources for the construction of this pyramid are debatable [4].

There is an abundance of literature on the subject of instruction methods in general. However, the very specific instruction of medical residents, which combines practical training, theoretical instruction and guidance by experienced physicians, makes it difficult to draw a parallel with instruction methods in general. There are very few studies specific to medical instruction and none with the design proposed in this study.

Two of the methods that proved to be the most beneficial in the study are used insufficiently in the current approach to instruction: access to self-evaluation; and the presence of alternatives to lectures (Figure 2) [2]. The lack of use of these teaching methods is probably related to their time-consuming nature and the investment they require from teachers. The development of digital learning tools is definitely an answer to these time consumption concerns. The effectiveness of e-learning in education has been demonstrated [5]. E-lectures are widely used for conferences (slide-shows combining sound and video). The methods of e-learning or MOOC (Massive Open Online Courses) have the dual advantage of a massive diffusion of intuitive information, limiting the preparation time for teachers. Thus, the average level and quality of instruction could be significantly improved by selecting the most thorough and current scientific content and combining it with the best pedagogical methods [6].

The current generation is ready to learn through technological media; students are ready to use digital tools and would like to have a national source to refer to.

As a perspective, a national (or European) framework for continuing education could be electronically delivered by way of a very precise teaching calendar, as a calendar is one of the most important tools for an efficient learning approach [2].

One relevant point is the association between the variable ‘supplementary medical diplomas >2′ and student dissatisfaction. Might we explain this association by the excess work required to carry out these additional medical diplomas? Maybe the dissatisfaction of the students leads them to register for supplementary training? The solution could be to integrate into the core curriculum a maximum number of trainings in order to limit the proliferation of additional trainings.

The results of this study also show that a combination of teaching methods optimizes the quality of theoretical training, in terms of student satisfaction and knowledge (Figure 2) [7, 8]. Finally, this study suggests that information taken directly from the guidelines better enforces the knowledge, whereas no formalized instruction on a topic leads to a lack of knowledge about the topic. These results could seem intuitive, but had to be demonstrated, and they validate the concept of optimal versus minimal training developed by the European Society of Cardiology [9].

Study limitations

The main limitation of this study is the fact that it represents only one nation's view, thus the interpretation has to be limited to France. We could not get an exhaustive list of the student's email addresses; thus, and due to the variability of responses among cities, Saint-Etienne University is not represented. The study is not exhaustive and represents a panel of about 30–35% of the residents.

Conclusion

This study demonstrates moderate satisfaction of French residents in cardiology with the quality of their theoretical training (knowledge development) compared with their satisfaction with practical training (skills acquisition and behavioural training). Five variables, including four teaching modalities, independently predicted a higher score in the knowledge test. These variables were seniority >3 years; access to self-assessment; the use of teaching methods other than lectures during explicit learning; systematic discussion of problematic decisions with senior doctors (case-based discussions); and the opportunity to prepare lectures by themselves rather than attending courses prepared by experienced doctors. For a given item, the quality of knowledge was positively influenced when students were familiar with the guidelines covering the topic, and was negatively influenced when the topic had not been covered by the training programme. The results underlined in this study can be used as landmarks to guide the essential instructional needs. The use of electronic resources may be a particularly effective approach to the objective of diversification of teaching and advancing medical education. To propose this type of evaluation throughout Europe would be of interest and would help with the understanding of national differences and organizing the harmonization of education throughout European countries.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.


Acknowledgements

The authors would like to give special thanks to Lina Yakoubian for the help provided with the writing of this manuscript.


Appendix A. Supplementary data

(22 Ko)
  
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