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ORIGINAL ARTICLE
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Teaching electrocardiogram to first MBBS students in the department of physiology during COVID-19 pandemic: A challenge


1 Department of Physiology, Burdwan Medical College, Bardhaman, West Bengal, India
2 Department of Pharmacology, Burdwan Medical College, Bardhaman, West Bengal, India
3 Department of Community Medicine, Medical College, Kolkata and Assistant Director of Medical Education, Government of West Bengal, Kolkata, West Bengal, India
4 Department of Physiology, Lady Hardinge Medical College, Delhi, India

Date of Submission08-Jun-2020
Date of Decision20-Sep-2020
Date of Acceptance25-Sep-2020

Correspondence Address:
Arunima Chaudhuri,
Krishnasayar South, Borehat, Burdwan, Purba Bardhaman - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_439_20

  Abstract 


Background: Continuing Medical education during the COVID-19 Pandemic has been a great challenge to Medical educators, especially teaching clinical skills online. Aims: The study aims too study the efficacy of teaching ECG in online mode to first MBBS students in the Department of Physiology. Materials and Methods: There are 200 students in the first MBBS batch at Burdwan Medical College. Our method of teaching was flipped classroom-assisted self-directed learning. For teaching ECG to our students we had first arranged for presession MCQ to assess the initial level of knowledge. We had then provided the students with PowerPoint presentations with voice narrations for their self-study, following which the students were divided into batches of twenty and each batch had a team leader and a facilitator. These small batches were shown videos of instruments, methods of recording ECG, normal and abnormal ECG along with explanations in multiple sessions (10). Doubt clearing sessions were arranged for each batch and these sessions were brainstorming. The students were assessed with MCQs (10 marks each Session), oral questions, short answer type questions, spots, and problem-based questions. We also took a feedback survey from the students and provided the students with feedback regarding their performance. Results: MCQ assessments of students in Pre and Posttest session on ECG teaching classes were 50.39 ± 19.41 vs. 65.25 ± 9.14; P ≤ 0.001**. Students performed significantly better in MCQ assessments of students on Normal parameters of ECG assessment as compared to Abnormal ECG parameters: 67.25 ± 10.98 vs. 63.157 ± 7.399; P = 0.000424**. Results of Written Examination and Viva Examination of students in ECG classes were 64.844 ± 9.923 vs. 71.89 ± 10.49; P ≤ 0.001**. Conclusions: The online method of teaching ECG was a success in the institution as observed in this study as observed in the assessment. Students performed better in viva in online exam for ECG and students were satisfied with online delivery.

Keywords: COVID19 pandemic, electrocardiogram, students



How to cite this URL:
Chaudhuri A, Paul S, Mondal T, Goswami A. Teaching electrocardiogram to first MBBS students in the department of physiology during COVID-19 pandemic: A challenge. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=321296




  Introduction Top


Coronavirus Disease- 19 has posed a challenge for medical educators as medical education was rarely carried online before the present crisis. There are also not many studies regarding the procedure by which medical education can be continued online and little is known about the impact of online education on medical students. Effectivity of online learning for undergraduate medical students remains a field of medical education that requires thorough exploration.[1],[2],[3]

Medical students need to acquire different skills during their undergraduate education so it is very difficult to teach them online without prior preparation. The use of technology in education has increased in recent years and online learning has become a common teaching mode. Pei and Wu in 2019[4] in their explorative research found no evidence to demonstrate that offline learning works better and suggested that online mode can also be considered as a potential method in undergraduate medical teaching.[4]

The COVID-19 Pandemic and nation-wide lockdown have brought a sudden change in medical education across the globe. Many medical colleges and health universities have taken the initiative to start teaching and learning using various online platforms on their own as there were no definitive directives from statutory bodies. Undergraduate teaching is being conducted by various methods using various online platforms by many medical colleges without any uniformity.[5] Medical educators, especially in West Bengal are usually habituated with the offline mode of teaching, and converting this offline mode of teaching into an online mode suddenly is really challenging. We have to also see that we provide adequate knowledge and skills to our students as they will be doctors of tomorrow and will deal with life and death of patients, so there can be no compromise made in medical education.

According to the new MCI curriculum implemented in 2019[6],[7] we are setting up skill laboratories in all teaching Institutions. However, in a developing country like India there are lots of constrains to bring about sudden changes, there are financial issues regarding budget also. All these factors have increased our challenges further.

In the age of modern technology, incorporating online teaching in traditional curriculum needs to be considered in undergraduate Medical education. The use of online learning has vastly increased since 2012 in higher education.[8],[9],[10] Hence, teaching online without adequate knowledge in technology posing a huge challenge.

Online learning might be equally effective as offline learning for the topics but this domain still remains to be studied. Objective assessments filled with multiple choice questions are more appropriate for the assessment of low-level learning goals, online learning, therefore, might only be as effective as offline learning when the learning goals are simple.[3],[11]

Technology, in the wake of COVID-19 has already forced us to examine and explore more fundamentally the purpose and process of teaching; what constitutes valid knowledge, and how best medical students can acquire it. In such an hour of crisis, with geographical and time barriers to education, technology can be used in innovative way for maintain learning. This crisis may have given the medical educators an opportunity to divulge into unexplored areas of technology-based medical education. When COVID 19 resolves, transformative changes will possibly occur in medical education with the use of emergent technology.[12] Multiple studies need to be conducted across the country to know the effectiveness of these teaching and learning tools.[5]

The present study was conducted to observe efficacy of teaching ECG in online mode to first MBBS students in the Department of Physiology. The electrocardiogram (ECG) is one of the simplest and oldest cardiac investigation available and it can provide lots of useful information.[13] It is more difficult to teach students clinical skills specially in early medical schools online. Hence, this topic which is relevant, essential to all medical students and doctors was chosen for the present study.


  Materials and Methods Top


The study was conducted in the Department of Physiology, Burdwan Medical College after taking Institutional ethical clearance (Memo No: BMC/I.E.C/127: Dated March 12,/2020) in a time span of 1 month. Two hundred medical students admitted to the first MBBS batch were included in the study.

First all 200 students were included in a WhatsApp group and a Google class room. We first taught basic cardiovascular physiology then only started teaching ECG.

They were provided with PowerPoint presentations with narrations and audio on clinical examination of cardiovascular system, which included history taking, general examination, and examination of cardiovascular system proper. They were then divided into small batches of twenty and shown video presentations on the topics along with brain storming sessions. Each student was given a question which they had to present orally or with a video presentation in front of the whole class. All their queries were answered by their facilitators. The session had a pretest and posttest MCQ assessment and students were provided with feedback. Google form was used for MCQ assessments. No negative marking was done. Each MCQ session had 10 marks. Five pretest and five posttest sessions were conducted for ECG assessment.

Then they were provided with power point presentations on ECG. Three such presentations were shared with them along with a video showing instrument and procedure (49, 50, 48 slides). Each part of ECG was explained to them with images and voice messages. Four you tube videos were uploaded (1 h 5 min, 55 min, 1 h 15 min, 12 min). PowerPoint slides and again Images and voice messages had to be supplied as many were still not following these. Hence, we took up each component and send a voice message along with an image to cope up with this problem. As many (28) were not able to download the whole presentations in their mobile and they came from rural area and had financial problems so we came up with this solution. We had contacted them in their mobile numbers after observing their performance which revealed these issues. The you tube videos were also uploaded as per demand of the students (they were able to watch them any time in areas where Wi-Fi connections were available).

Hence, they had knowledge about the conducting system of the heart, conduction velocity of different parts, different waves of EGG and intervals, the calibrations on the ECG strip and the normal ECG recordings of all leads.

They were taught how to interpret normal electrical axis of the heart and the hexa-axial system. They were shown YouTube Videos and animations as per their demand Following these again short group discussion was done which were brain storming. We then sent them small strips of ECG individually which they had to explain in front of the class. Each day, 10 students were assessed. Hence, all students had to actively participate in all sessions and we teachers just acted as facilitators. They had a written question answer session on this topic and they wrote their answers in Microsoft word and sent it to their facilitators. There was a time limit for answering. We had a departmental meeting and answers and markings were decided and all faculties followed the guideline. The questions were problem based and students received feedback of all answers. We had sent back their answer scripts with marks and comments for all answers in their E-mail.

Then, we started sessions on abnormal waveforms of ECG and only a few topics relevant for first MBBS students were taught to them: Heart block, Reentry Phenomenon, Axis deviation, Myocardial ischemia and infarction, effect of electrolytes on ECG. You tube videos uploaded were two in number, but voice messages and images were plenty as they had lots of queries. We had arranged for sessions in Google meet for only interaction, and each meet session only included 20 participants. These topics were discussed repeatedly with brain storming sessions, voice messages and problem-based questions to make them interesting and interactive. For assessment of these sessions students were provided with ECG strips individually and they had to explain these. There were MCQ examinations and written test conducted to assess their knowledge.

All our students can now identify the instruments, the different leads of ECG and their position. They are able to define the different waves of ECG, intervals and their causes, vectors. But to achieve this it required much more involvement of faculties. They can calculate heart rate, different intervals for any ECG strip, interpret any abnormal rhythm. We had taken multiple sessions to assess them and until they were able to identify and answer correctly they had to repeat their tasks.

We have assessed their knowledge multiple number of times during ECG sessions with problem based MCQ questions, spots, viva and written tests. Each day 10 students were selected randomly and sent ECG strips and diagram of instruments, which they had to present in front of the class either in audio or video presentations. Number of MCQS conducted was five. Open book examination (OBE) and open-book, open-web (OBOW) examination was implemented in this study. We were able to impart knowledge on cognitive domain (knowledge based) for this topic, which is adequate for first MBBS students. Before the sessions in the pretest, they were not able to answer many questions which they were able to answer after the teaching learning sessions. Our results section will demonstrate this claim.

Pre and Post results could have been better as the students were staying at home and they could look into their books. To prevent this following measure were taken:

  1. All MCQ examination had a time limit and the students could only attempt once
  2. The time got recorded in the sheets and the link was only open for a short interval of time
  3. For pretests, we did not give any intimation to the students that exams will be conducted on that day
  4. For posttests, the questions were problem based and they were not able to answer at all until they studied and built up concepts (results will show that not a single student could score full marks.


We took a feedback survey from the students regarding their impression on the method and impact of teaching physiology in online mode. There were ten questions in the survey. All 200 students participated in the survey.

Statistical analysis

The computer software “The computer software ”Statistical Package for the Social Sciences” (SPSS) version 16 (SPSS Inc., Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.,). Long produced by SPSS Inc., it was acquired by IBM in 2009. Current versions (post 2015) have the brand name: IBM SPSS Statistics. SPSS Data Collection and SPSS Dimensions were sold in 2015 to UNICOM Systems, Inc., a division of UNICOM Global, and merged into the integrated software suite UNICOM Intelligence (survey design, survey deployment, data collection, data management and reporting) was used for analysis of data. The difference between the groups was considered significant if the analyzed probability values (P value) were P < 0.05* and highly significant if P < 0.01**, respectively. T test was used to compare the data (prepost is for paired t-test), other sessions were compared using unpaired t test.


  Results Top


Results of five MCQ assessments of students in both pre- and post-test session on ECG teaching classes were 50.39 ± 19.41 vs. 65.25 ± 9.14; P ≤ 0.001** (highly significant). Hence, we observed a significant improvement in performance of the students following the ECG classes [Table 1]. Results of MCQ assessments of students on Normal and Abnormal ECG parameters were 67.25 ± 10.98 vs. 63.157 ± 7.399; P = 0.001** (highly significant). So, we may say that students had significantly better knowledge on normal ECG parameters as compared to abnormal ones [Table 2]. Results of Written examination and Viva examination of students in ECG classes were 64.844 ± 9.923 vs. 71.89 ± 10.49; P ≤ 0.001** (highly significant). The students performed significantly better in oral examinations as compared to written tests [Table 3]. There was no difference according to gender in the present study.
Table 1: Results of multiple choice question assessments of students in pre- and post-test session on electrocardiogram teaching classes

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Table 2: Results of multiple choice question assessments of students on normal and abnormal parameters of electrocardiogram (three multiple choice questions for normal electrocardiogram and two for abnormal electrocardiogram)

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Table 3: Results of written examination and viva examination of students in electrocardiogram classes (postsession only)

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Two hundred 1st year students participated in the present study. In the feedback survey conducted on the online teaching mode only 62% were satisfied. [Table 4] However, according to facilitators it was easier to monitor all students in this method as compared to the offline mode as we could individually pay attention to them but it required much more involvement on their part to make this program effective
Table 4: Questions and results of survey

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  Discussion Top


The present study conducted in the Department of Physiology of Burdwan Medical College students performed significantly better in all examinations following Theory and Practical online classes on ECG and posttest sessions showed better performance of students. As per new MCI guidelines we were asked to implement competency based medical education for the current first MBBS batch.[6],[7],[12] The COVID-19 pandemic and lockdown and online teaching forced us to implement many new methods in our teaching learning program to make this somewhat successful.[5] The basic concept of online learning is more than 150 years of age.[4]

Students seldom learn by merely sitting in classes listening to teachers. For effective learning, it is essential that students must interact and relate their learning to past experiences and apply it to their daily lives.[12] In previous years, we used to teach them and they used to hear and see and participate in examinations conducted. This year due to the forced lockdown they had to actively learn and we could only act as facilitators. We have observed that (80%, as they scored 60% or more) most of the students have understood very well in this process and the way they explain their concepts to their classmates is also quite different from our traditional methods of explaining things. The students are also able to cope up better with the explanations given by their classmates and this was an observation of the present study.[14],[15],[16],[17] The way the younger generations look into different things is somewhat different from the way we teachers look at same things. We all are lifelong learners. To make teaching learning more effective we have to modify ourselves to decrease this gap between teachers and students. Teachers need to incorporate audio, video, links to other virtual worlds and create authentic, interactive problem-solving activities that construct meaningful knowledge.[12]

A developing country like India have lack of infrastructure (Classrooms in many government colleges are small as compared to number of students, there are frequent power cuts, lack of generator support, many are lacking skill laboratories till date). Online learning can bridge the gap and strengthen quantity and quality of medical education as it is more flexible and adaptable.[12],[14]

Most of our students are very technology friendly and many of them can present different topics very well if motivated. Among the two hundred students, 152 had good knowledge in computers and networking. The rest 48 were having lots of problem to cope up. Hence, we encouraged them to teach rest of their classmates. Initially they were not willing to teach, as nobody responded to our appeal. Hence, we posted in their group that we teachers are not able to cope up with the present online crisis (we had to start teaching everything online all of a sudden without any support from our higher authorities and guidelines, depending only on our individual efforts, so this was a crisis that we teachers faced initially) as many of us are not that technology friendly. We gave them a few technological problems and requested them to help us to learn from them. They made beautiful video presentations and posted in the group, so all their classmates followed these. At present the whole class is able to cope up with their problems regarding use of computers, network. The MCI has implemented foundation course in the new curriculum.[15]

We had given them some study material and asked them to prepare video presentations and post these in their group after first discussing with their respective teachers. Throughout the whole study, they were always guided by their peers. These presentations were also better than the outcome that we had expected from them as they are more technology friendly. The faculties assessed the video presentations, in which the students drew diagrams and explained every aspect adequately. These sessions might also helping them to build-up team spirit and exchange their ideas with one another.

They were not satisfied with this method of teaching learning that is what they have stated in their feedback survey. 62% were satisfied with the present teaching method, but all of them claimed that they want to return to their classes as early as possible, 95% claimed that they wanted this online support system to continue even if they were back in their traditional classes and they all claimed that they want online support system to start from the very beginning of next session.

Their opinion showed that these sessions are too stressful for them and they all had to participate actively. Teachers now know their mobile numbers and follow them regularly if they miss any session. For stress level assessments of students' anonymous survey was used so there was no scope of violation of research ethics and direct identification of students. They were even allowed to comment on teaching learning sessions in fifty words. Maybe the sessions are stressful, but we did not have any other option as we had to teach them online and ensure that they have learnt all objectives and competencies as advised the new curriculum of MCI implemented in 2019,[6],[7] CBME, which is an outcome based approach. We have assessed that all our students could achieve at least 50% marks[6] following the teaching sessions which is the minimum criteria that has to be attained by them as per MCI guidelines. Pretest session score was50.39 ± 19.41, so all were not able to attain 50% score before the session.

The modern technological transition has opened a variety of online modalities to augment teaching and learning for medical education. However, the use of technology in medical education is challenging and also needs due consideration to realize its impact. These challenges are as follows: Technical issues related to inadequate technical infrastructure; unreliable internet connectivity for smooth conduct of online teaching sessions; absence of institutional strategies to facilitate online teaching; financial costs; pedagogical insecurity; insufficient preparedness of faculty; in effective use of online teaching tools and learning management systems; time constraints; lack of appropriate tools for clinical teaching; and lack of direct contact between teachers and students.[11],[12],[18]

These constraints have forced us to reflect on the immediate needs of both the teacher and the student in medical education. In the midst of the COVID-19 crisis, the medical educators' community needs to put its academic experience into practice and prioritizes a forward-thinking to bring out practical solutions for the benefit of medical students. Online teaching, learning, and assessment in medical education are still relatively new; however, it has the potential to become mainstream in the near future.[5],[12]

The Medical council of India in the new curriculum implemented in 2019[6],[7] had advocated teaching in small groups and to encourage active learning. In the present study, we have tried to follow this method while conducting the teaching learning program for our students. But to make this program effective the facilitators had to devote lots of time and energy for the students.


  Conclusions Top


The online method of teaching ECG was a success in the institution as observed in this study as observed in the assessment. Students performed better in viva in online examination for ECG and students were satisfied with online delivery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

 
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