Remarkable advances are regularly made in the science, clinical practice, and procedural applications of interventional cardiology, challenging the interventional cardiologist to systematically integrate new knowledge into a demanding, complex, and fast-paced environment. The rapid expansion of the evidence base for cardiovascular medicine has occurred contemporaneously with transformative changes in information technology. The Internet originated as a Department of Defense project in 1969, and the World Wide Web entered the national consciousness in 1991 with the introduction of the first graphical web browser, called Mosaic. Over the next few decades, the World Wide Web has become a ubiquitous presence in daily life that has affected all aspects of communication and social interaction. Not surprisingly, the Internet has also become a major means of distributing a broad range of educational materials. The Internet was so pervasive that in 2013, there were more than 2 trillion Google searches representing nearly 6 billion searches per day, presumably by individuals seeking information.1 With the rapid growth of mobile devices, people can basically access information and learn anywhere and at any time. Online learning has affected educational domains from preschool to professional education, and each area has its unique attributes and challenges. In this chapter, however, only the most important aspects of web-based learning as it pertains to the interventional cardiologist will be presented.
Adult learning strategies (called andragogy) originated in ancient times; for example, both Plato’s Academy and Aristotle’s Lyceum were focused on adult education.2 Although much academic work at American universities has focused on children from kindergarten through high school (known as pedagogy, or the science of teaching children), adult learning theory expanded and acquired a stronger theoretical basis with the work of Malcolm Knowles and others in the 1970s. Adult learning theory continues to evolve, and newer theories known as “transformative learning theory” are being actively explored in the academic literature. Transformative learning relates to changing one’s perspective on one’s self and one’s place in the larger social context.
Adult learning theory, according to Knowles, is based on a number of assumptions:
As a person matures, his or her self-concept moves from that of a dependent personality toward one of a self-directing human being.
Adults accumulate a growing reservoir of experience, which is a rich resource for learning.
The readiness of an adult to learn is closely related to the developmental tasks of his or her social role.
There is a change in time perspective as people mature—from future of knowledge to immediacy of application; thus, an adult is more problem-centered than subject-centered in learning.
Adults are mostly driven by internal motivation, rather than external motivation.
Adults need to know the reason for learning something.2
An important assumption of adult learning relates to accumulated life experiences as a rich resource for learning. Indeed, medical residency, general cardiology fellowship, and interventional cardiology training are steeped in the ongoing experiential development of the core competencies of the Accreditation Council for Graduate Medical Education, which include medical knowledge, patient care, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication. In each of these domains, adult learning theory can lend insight into the kinds of behaviors that are best associated with acquisition and integration of new knowledge into established practice patterns. The reduction in work hours over the past decade has additionally fragmented the time that residents and fellows spend in the hospital engaged in patient care and education. Self-directed learning, initially known as “self-teaching,” has become a critical component of physician education. “Virtual learning environments” including web-based learning may be well suited to many aspects of self-directed learning but success may vary significantly among individuals and across cultures.2
Much of the learning associated with interventional practice occurs when the interventional cardiologist confronts a new problem or a constellation of problems that are unfamiliar. Adult learners typically learn based on specific needs, and learning is reinforced when there is an immediate application of learning. Thus new patient problems often present “teachable moments” that offer unique opportunities to both learn and integrate complex new information. Adults often want to choose what they learn and how to learn it; web-based learning environments offer a broad spectrum of content, and learners can seek the kinds of learning experiences that are best suited to them as individuals. Adult learners like to know why they need to learn certain types of information; learning new information as it pertains to a specific patient or problem can fulfill this inherent need.
The arrival of enhanced social media capabilities of Web 2.0 has offered increasing opportunities for professional interactions to occur that help to establish “communities of practice” that result when interventional cardiologists interact regularly around common clinical problems or concerns. These activities had traditionally occurred during local case presentation conferences or during a cardiac catheterization laboratory conference. For cardiologists who are more separated geographically from colleagues yet still wish to interact regularly and share patient experiences or challenges, web-based learning methods may allow for the development of “virtual communities of practice” in which participants may use the powerful communication tools of the web to created shared meaning and experience, to observe more experienced operators perform common procedures, and to develop a sense of community with a group of colleagues who share their clinical interests.
In 2010, the US Department of Education3 performed a meta-analysis of more than 1000 scientific studies of online and web-based learning focusing on those reports that (1) contrasted web-based and face-to-face learning, (2) measured learner outcomes, (3) employed rigorous scientific methods, and (4) provided adequate data to calculate the magnitude of the learning effect. With respect to the evidence based on adults, the key findings of this meta-analysis included the following:
Students in online conditions performed modestly better, on average, than those learning the same material through traditional face-to-face instruction.
Instruction combining online and face-to-face elements had a larger advantage relative to purely face-to-face instruction than did purely online instruction.
Effect sizes were larger for studies in which the online instruction was collaborative or instructor-directed than in those studies where online learners worked independently.
The effectiveness of online learning approaches appears quite broad across different content and learner types.
Effect sizes were larger for studies in which the online and face-to-face conditions varied in terms of curriculum materials and aspects of instructional approach in addition to the medium of instruction.
Elements such as video or online quizzes do not appear to influence the amount that students learn in online classes.
Online learning can be enhanced by giving learners control of their interactions with media and prompting learner reflection.
A large number of important unanswered questions remain with respect to web-based learning, especially related to the specific techniques in web-based instruction that make online learning most effective. Over the past few decades, numerous academic and professional organizations have developed that support the educational science underlying theories of online learning, including Merlot (Multimedia Resource for Learning and Online Teaching; www.merlot.org), Sloan-C (Sloan Consortium; www.sloanconsoritum.org), and the National Science Digital Library (www.nsdl.org). Additionally, the number of academic journals publishing original research in web-based learning continues to grow.
Mobile technologies and smartphones have transformed the cultural landscape and the opportunities for information delivery. A recent survey in Time magazine reported that 9 of 10 Americans carry a mobile device and access it regularly. While mobile phones were nearly nonexistent a generation ago, Time’s poll reported that currently 25% of people check their phones every 30 minutes and 20% do so every 10 minutes. Thirty-three percent of Americans feel anxious if they are separated from their phones for even short periods of time. Seventy-five percent of Americans age 25 to 29 years sleep with their phones, and twice as many people would pick their phones over their lunch if forced to choose.4
A full discussion of “mobile learning” or “just-in-time learning” is beyond the scope of this chapter, but it is important to consider the potentially transformative implications of information delivery to learners in real time and at the point of care. Just-in-time education can potentially provide patient-specific answers to clinical questions at the moment the provider needs to know. The opportunities for clinically relevant learning at highly “teachable moments” are obvious. Text-based applications running on the web, such as UpToDate, ClinicalKey, mobile manuals, Epocrates, and many others, offer mobile access to specific clinical information on mobile devices. Increasing levels of integration with electronic medical health records for specific patient allows the possibility for both alerts and instruction relevant to specific patient care situations to be offered in real time. Such integration of electronic medical health records with just-in-time education is still in its infancy. As a particular example, the rapidly expanding fields of cardiovascular genetics and genomics are producing new knowledge at a rapid rate, and this information will not be widely familiar to many practicing physicians. Similarly, physicians will often be uncertain as to when such information is even relevant for a particular patient or disease state. Thus cardiovascular genetic data might be examples of “chunks of knowledge” that could provide “just-in-time” education to practicing cardiologists caring for patients with certain cardiomyopathies.
Web-based learning is still in an early phase in subspecialty medical education, and many challenges face the organizations and groups that develop learning materials for interventional cardiologists. The rapid expansion of learning platforms, mobile devices, and technology standards has offered both opportunities and challenges. One of the greatest challenges relates to the rapid evolution of knowledge and clinical information. Case studies, guidelines, and clinical trial results can rapidly become obsolete as new science is developed. When clinical information is embedded in enduring materials, its relevancy is quickly dated and it requires significant financial resources and effort to keep clinical information up to date, especially when it is in noneditable formats such as video or web-based packages. Clearly, the current significant use of web-based learning sites would seem to confirm that physicians desire to use online resources in education, but objective demonstration of improved physician performance or patient outcomes from these learning interactions is still lacking, especially for online educational methods that teach cognitive or procedural skills.
The quality and reliability of much educational content remains uncertain. Whereas medical journals have formal peer-review processes that have been developed over many years,5,6 online content can appear on the web from any number of sources. Much of the web-based learning in interventional cardiology comes from major cardiology societies such as the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, the American Heart Association, or the European Society of Cardiology. Much of this content undergoes a form of peer-review. Other content may come from other Accreditation Council for Continuing Medical Education–approved sites such as universities or hospital-based research foundations. However, medical educational content can also be user-generated or even crowd-sourced from comment fields, blogs, or wikis, methods where the quality and source of information may be unclear.
Apps are small computer programs, or “applications,” that typically run on mobile devices such as smartphones or tablets (such as iPad or Google Nexus) but also on a computer or laptop. For medical uses, an app might contain mathematical formulas that allow one to calculate creatinine clearance, CHA2DS2-VASc score for atrial fibrillation stroke risk, or a Thrombolysis in Myocardial Infarction (TIMI) risk score. Other examples of apps are email, games, or mobile web browsers.
Blended learning refers to using web-based teaching methods together with more traditional classroom-based methods. This is sometimes referred to as hybrid learning, or “flipping the classroom,” since the latter allows lectures to be given asynchronously via the web while classroom time is reserved for higher level, integrative learning.
Blog, derived from the word “weblog,” is an e-learning or social media tool that allows the ongoing discussion of a particular topic or theme, often in response to a prompt. Blogs allow social interaction and engagement with a wider audience of blog readers or members. Topics are often maintained and archived in reverse chronological order for ongoing review.
Content is a broad term that describes the actual material to be received or learned. In the electronic world, content varies widely in complexity ranging from very small elements (eg, a phrase, image, or sound) to complex larger structures such as learning exercises, lessons, entire curricula, or even games. In some contexts, a simple piece of content might be considered a “knowledge chuck” or “learning object” that could be used as a modular building block for e-learning.
Learning Content Management Systems (LCMS) are required to administer all of the complex relationships that exist among pieces of content such as organization, storage, assigning meta-tags, previous uses, productions steps, relationships with other content, technical specifications, editorial review status, copyright considerations, or other management functions. Optimally content management systems would interact seamlessly with the content, with authoring tools, with production processes, with learner management systems, and with content delivery systems.
E-learning is a broad and evolving term that involves the use of electronic media and/or the Internet to promote education. E-learning may encompass multiple types of technology-facilitated education including multimedia, computer-based training, online education, or distance learning.
Experience API (formerly known as “Tin Can”) is an API (application programming interface) that has been called the “next-generation SCORM (Sharable Content Object Reference Model).” Experience API will allow data from a diverse set of educational activities to be collected and recorded by a learning management system in a fashion that facilitates the creation of online curricula that mix online learning with traditional (real-world) educational activities.
Learning management system (LMS) is the software that focuses on the management of the learner, or “end-user.” An LMS typically manages the administrative aspects of educational websites including the tracking of users and membership, documentation of interactions, reporting, and other common administrative functions such as username, passwords, and e-commerce. Some systems manage certificates, transcripts of work completed, or a broader learning portfolio.
Learning objective is a clear, structured, and measurable statement of the behavior or performance that the learner needs to accomplish to be sure that the desired learning has actually occurred. A well-structured learning objective has 3 parts: a measureable verb, the important condition under which the performance is to occur, and the definition of acceptable performance.
List serv is an automated method for managing and distributing content by email to a specified recipient list. A list serv may support or replace other e-learning functions by pushing content to users who prefer to receive information by email. The resulting communications resemble a newsgroup or forum. List servs have been used by academic catheterization lab directors to facilitate educational correspondence.
Massive open online courses, or MOOCs, allow a single instructor to offer a course to a nearly unlimited number of learners simultaneously. Perhaps the best-known platform is Coursera, which is an online provider that partners with many of the best-known universities around the world to offer full courses for anyone with an Internet connection and at no cost. MOOCs typically offer many of the advantages of online learning including providing master instructors to teach the courses and peer assessments to review learner-generated content. Blended learning is a common aspect of MOOC courses. One MOOC instructor, Harvard’s Michael Sandel, became so famous after teaching a course called “Justice” that he achieved celebrity status in Korea, and his philosophy course has had more than 20 million views in China (with subtitles).7
Needs assessment is a structured procedure that occurs prior to creating e-learning material for identifying and prioritizing the educational needs of the community. This is accomplished by analyzing the gap between present educational state and the desired state or outcome.
Podcasts are electronic files, often audio and video, that are distributed over the Internet. These are typically viewed or heard on computers or mobile devices such as smartphones or personal players such as iPods.
SCORM, or Sharable Content Object Reference Model, allows educational content to be shared widely by differing learning management systems by specifying the standards and coding for web-based e-learning. Thus SCORM-compliant educational modules created with one product can be shared on educational sites using a different learning management system. SCORM was created as part of the Advanced Distributed Learning (ADL) Initiative from the Department of Defense.
Social media is often experienced as a phenomenon in mass markets but is increasingly used in professional environments including web-based interactions for physicians. Many of these sites allow the user to create a personal profile that is shared widely. Examples include Facebook, Twitter, LinkedIn, Doximity, Skype, Youtube, and many more.
Synchronous and asynchronous e-learning: Synchronous learning requires that both the teacher and learner be present at the same time. Common examples would include a classroom lecture or a traditional seminar in a classroom. In an e-learning environment, the interactions would require the educator and the learner to be online at the same time to allow direct interaction as in a video-conference or virtual classroom.
Asynchronous learning allows the educator and the learner to be separated by both space and time. Technologies such as email, blogs, discussion boards, social networking, and wikis support asynchronous e-learning and allow greater flexibility in the time domain. Learners may work at their own pace, review material repeatedly, and feel less time pressure when reviewing educational material or producing responses.
Web 2.0 is a broad term given to the second generation of web methods that allowed for sharing of content among participants and for greater creation of content by users. Most Web 2.0 applications use dynamic generation of pages, typically from content held in a database, rather than relying on static, hard-coded web pages. Wikis, video sharing, and enhanced social networking are enabled by these enhanced technologies.
Webcast is a transmission of audio and video over the Internet much like a television broadcast. This technology delivers prepared educational content to a learner over the Internet with limited interactivity.
Webinar uses more advanced Internet technologies than a webcast, allowing for audience participation and interaction with the learning activity. It may be a presentation, workshop, lecture, or seminar that is managed over the web. In a webinar, the audience can interact with the teachers and with each other in real time, and the overall educational encounter can be archived for later, asynchronous viewing.
Wiki is a website or related environment where the end-users themselves can create and edit content individually or by collaborating with others. Typically a wiki requires no additional software and allows for distributed or crowd-sourcing creation of content. Wikipedia is the best-known example.
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