Mechanisms in cardiovascular diseases: how useful are

medical textbooks, eMedicine, and YouTube?

Samy A. Azer

Advan in Physiol Edu 38:124-134, 2014. doi:10.1152/advan.00149.2013

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Adv Physiol Educ 38: 124134, 2014;

doi:10.1152/advan.00149.2013.

Staying Current

Mechanisms in cardiovascular diseases: how useful are medical textbooks,

eMedicine, and YouTube?
Samy A. Azer
College of Medicine, King Saud University, Riyadh, Saudi Arabia
Submitted 2 January 2014; accepted in final form 20 March 2014

mechanisms; cardiovascular conditions; textbooks; eMedicine; YouTube; basic sciences; pathogenesis; linking basic and clinical sciences; integration of knowledge
CARDIOVASCULAR MECHANISMS are integral components in understanding pathophysiological changes of diseases and in
linking basic and clinical sciences in a meaningful way (20).
They also enable learners to examine the etiology and
contributing factors of cardiovascular diseases as well as the
chain of changes caused by the disease processes at molecular, cellular, organ, and body system levels (7, 36). Cardiovascular mechanisms can also provide an explanation for
the patients presenting symptoms and elicited clinical
signs. Therefore, mechanisms represent a system of casualty
outlining processes caused by a disease at its different stages
and providing an explanation for the changes. Mechanisms
could also accommodate not just basic sciences but also

Address for reprint requests and other correspondence: S. A. Azer, Medical

Education Dept., College of Medicine, King Saud Univ., PO Box 2925, Riyadh
11461, Saudi Arabia (e-mail: azer2000@optusnet.com.au).
124

biopsychosocial and behavioral aspects related to cardiovascular diseases (7, 5, 30).

Considering the educational outcomes obtained from learning mechanisms of diseases, most medical curricula are enforcing mechanisms in their teaching/learning approaches. For
example, in problem-based learning (PBL), case-based learning, task-based learning, and related activities, many schools
have adopted mechanisms in their case template (22, 39). The
educational outcomes that can be obtained from mechanisms
include 1) enabling students to explain their hypotheses for the
patients problems identified; 2) encouraging students to integrated knowledge from basic and clinical sciences as well as
biopsychosocial issues in mechanisms; 3) stimulating students
to explore pathophysiological changes at molecular, cellular,
organ, and body system levels; and 4) using basic sciences to
interpret patients symptoms, clinical signs, and the results of
clinical investigations (5, 20, 36).
With the introduction of integrated and self-regulated learning to most medical schools such as PBL and case-based
learning, medical students tend to use a range of learning
resources such as Google, YouTube, and eMedicine (1, 2, 4, 6,
9, 22, 37). This does not necessarily mean a shift from using
recommended or prescribed textbooks. Despite some limitations, textbooks remain one of the key learning resources, but
most student rely, in addition, on online resources such as
eMedicine and YouTube to enhance their understanding and
consolidate the knowledge they need for their learning issues
(14). eMedicine is one of the largest online clinical resources
available to medical professionals, medical students, and the
public. It comprises 6,800 articles, each of which is associated with 1 of 62 clinical subspecialty textbooks (41). Also,
eMedicine topics are authored by board-certified consultants,
and the articles are peer reviewed by several experts to which
the article belongs. YouTube is the largest internet videosharing site and is a useful tool in social communication,
advertising, and promoting learning resources to the public and
students (19). Although a few studies have shown that YouTube videos could be educationally useful, other studies have
reported concerns about misleading information included in
YouTube videos (4, 6, 25, 26).
The aim of this research was to evaluate the usefulness of the
learning resources commonly used by students including medical textbooks, eMedicine, and YouTube videos on cardiovascular mechanisms, with particular emphasis on the clarity,
quality, and percentage of contents committed to cardiovascular mechanisms. These resources were selected because they
represent common resources used by medical students to prepare their learning issues. The research question for the study
was as follows: how useful are medical textbooks, eMedicine
(Medscape) topics, and YouTube videos in learning cardiovascular mechanisms? The focus was on the clarity, quality, and

1043-4046/14 Copyright 2014 The American Physiological Society

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Azer SA. Mechanisms in cardiovascular diseases: how useful are

medical textbooks, eMedicine, and YouTube? Adv Physiol Educ 38:
124 134, 2014; doi:10.1152/advan.00149.2013.The aim of this
study was to assess the contents of medical textbooks, eMedicine
(Medscape) topics, and YouTube videos on cardiovascular mechanisms. Medical textbooks, eMedicine articles, and YouTube were
searched for cardiovascular mechanisms. Using appraisal forms,
copies of these resources and videos were evaluated independently
by three assessors. Most textbooks were brief in explaining mechanisms. Although the overall average percentage committed to
cardiovascular mechanisms in physiology textbooks (n 7) was
16.1% and pathology textbooks (n 4) was 17.5%, there was less
emphasis on mechanisms in most internal medicine textbooks (n
6), with a total average of 6.9%. In addition, flow diagrams
explaining mechanisms were lacking. However, eMedicine topics
(n 48) discussed mechanisms adequately in 22.9% (11 of 48)
topics, and the percentage of content allocated to cardiovascular
mechanisms was higher (15.8%, 46.2 of 292) compared with that
of any internal medicine textbooks. Only 29 YouTube videos
fulfilled the inclusion criteria. Of these, 16 YouTube were educationally useful, scoring 14.1 0.5 (mean SD). The remaining 13
videos were not educationally useful, scoring 6.1 1.7. The
concordance between the assessors on applying the criteria measured by score was in the range of 0.55 0.96. In conclusion,
despite the importance of mechanisms, most textbooks and YouTube videos were deficient in cardiovascular mechanisms. eMedicine topics discussed cardiovascular mechanisms for some diseases, but there were no flow diagrams or multimedia explaining
mechanisms. These deficiencies in learning resources could add to
the challenges faced by students in understanding cardiovascular
mechanisms.

Staying Current
LEARNING RESOURCES AND MECHANISMS

adequacy of contents of mechanisms provided in these resources.

METHODS

Medical Textbooks

eMedicine Cardiovascular Topics

Selection of topics. eMedicine (www.emedicine.com) was searched
on October 12, 2013 for cardiorespiratory topics. The aim of this
search was to obtain a representation of the cardiovascular topics
commonly used by undergraduate medical students. The medical
textbooks searched in this study were used in identifying these topics.
A list showing these cardiovascular topics and mechanisms was
created and used in guiding the search of the eMedicine website.
Advanced topics and those required at the postgraduate level were not
included. To ensure that all evaluators were criticizing the same
content, PDF copies for each article (n 48) were printed out from
the eMedicine (Medscape) website on that day.
Evaluation tool. To ensure consistency among evaluators, appraisal
forms were constructed for this purpose. The forms used in evaluation
were similar to those discussed for medical textbooks. Due to the
continuous changes and updating/editing of eMedicine articles, the
evaluators were informed to use only the material given to them and
not to consult articles on the website.
Piloting the evaluation. Before the scoring system was applied to
the eMedicine topics, the study was piloted. A total of 10 topics (other
than those included in the study) were randomly selected and used for
this purpose. The assessors applied the scoring system independently.
None of the assessors discussed their findings or the outcomes of their
work. An Excel sheet was then produced, summarizing the three
assessors work, and the findings were discussed in a meeting. In this
discussion, reasons for inconsistencies were identified and discussed.
This process helped in improving the form as well as training the
assessors on how to critically evaluate each article. The three assessors independently applied the scoring system for another 10 articles.
The number of medical diagrams used in these topics to explain
mechanisms were also identified and counted. Thus, contents of
mechanisms were examined for content congruent with current needs
in integrated undergraduate medical curricula.
Assessing the articles. The three assessors then evaluated the topics
from eMedicine (Medscape) independently. Topics that were difficult
to evaluate and/or when there were disagreements among assessors
were discussed in a meeting. Consistency among the three assessors
was measured using Cohens interrater correlation (21, 43).
YouTube Videos on Cardiovascular Mechanisms
Selection of videos. From October 1 to October 15, 2013, the
YouTube website (www.youtube.com) was searched using the following key words: cardiovascular mechanisms, cardiovascular
pathogenesis, concept map cardiovascular, physiology mechanisms, heart diseases mechanisms, heart diseases pathogenesis,
and concept maps heart diseases. In the YouTube search, quotation
marks were used with these terms to specify that these terms must be
present. Only videos in the English language were identified, and the
related URL was recorded. The three assessors independently using
the search key words conducted the search, and the search results were
evaluated and used to compile a common pool that was used in further
analysis. The inclusion criteria were videos covering mechanisms or
pathogenesis of the cardiovascular diseases in adults. Videos were
excluded if they were 1) not in the English language, 2) an advertisement or news, 3) discussing signs or symptoms of diseases affecting
the cardiovascular system, 4) about patients with cardiovascular
diseases reflecting on their experiences or roles, 5) a lecture on
a cardiovascular disease, 6) about drugs used in the treatment of cardiovascular diseases, or 7) about a clinical examination of the cardiovascular system. Duplicated videos were excluded, and repeats were
treated as a single file for analysis. The repeat file with the greatest
number of hits was used for the analysis. For each video, the
following data were collected: title, duration of the video, number of
days on YouTube, total number of viewers, and name of the uploader/
creator (organization, group of people, one person). Because the
number of days on YouTube varied widely among videos, it was

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Searching for textbooks. The aim of this search was to obtain a

representative sample of textbooks in physiology, pathology, and
internal medicine to describe the clarity and adequacy and if there
were any deficiencies in the contents on mechanisms of cardiovascular diseases. The Google Book search engine was used to search for
textbooks covering human physiology, pathology, and internal medicine. The terms used in the search were physiology and human
physiology, pathology, and internal medicine. Textbooks in
English published from 2007 onward were selected. Only textbooks
intended for undergraduate medical students were included; textbooks
written for specialties in physiology, pathology, internal medicine, or
other health professionals were not included. Study guides or companion books were excluded. Additionally, the same search terms
were used to search Amazon (http://www.amazon.com) and Barnes &
Noble (http://www.barnesandnoble.com/) websites. Medical textbooks on human physiology, pathology, and internal medicine were
used in this study. These textbooks embodied a representative sample
of undergraduate medical textbooks prescribed in these programs and
comprise the following: 1) they are prescribed in most medical
schools worldwide, 2) they are regularly updated and several editions
have been produced over the years, 3) they are among the bestseller
medical textbooks as per Amazon and the publishers websites, and
4) they are reviewed in prestigious medical journals such as the British
Medical Journal, Journal of the American Medical Association, and
New England Journal of Medicine.
Evaluation tool. To standardize the evaluation of the information
on mechanisms, quantity was calculated from the actual page content
and percentage of content devoted to mechanisms, reflecting the
commitment of the authors to provide learners with an adequate
understanding of the topic (12). The percentages were calculated by
dividing the actual page count by the total number of pages committed
to cardiovascular diseases/topics and multiplying by 100. The total
number of images and tables in each chapter were identified and
counted. Images and tables explaining mechanisms/pathogenesis were
counted, and the percentages were calculated by dividing the actual
images or tables by the total number of images or tables in the chapter
and multiplied by 100. The clarity, quality, and adequacy of mechanism contents were ranked using a scale of 13 (where 1 poor, 2
average, and 3 adequate/optimum level).
Piloting the evaluation. The aim of piloting was to introduce the
evaluators to the tool, ensure that they were able to use it, and identify
any inconsistencies among the evaluators that might necessitate improvement of the tool (44). Before the tool was applied, three chapters
(other than those included in the study) were evaluated by the three
evaluators for their content on mechanisms. The results from the three
evaluators were placed on Excel sheets and were discussed in a
meeting. Inconsistencies and areas that were difficult to assess were
resolved through discussion until a final agreement was reached. The
process was repeated by evaluating three other chapters, and the
agreement between the evaluators was calculated again.
Assessing the textbooks. A total of 65 chapters from 17 textbooks
(7 textbooks on human physiology, 4 textbooks on pathology, and 6
textbooks on internal medicine) were committed to cardiovascular
diseases/system and blood vessels. These chapters were evaluated by
the three evaluators independently. The results from each evaluator
were placed on Excel sheets. The findings were discussed among the
evaluators. The agreement between the three evaluators was calculated using Cohens interrater correlation.

125

Staying Current
126

LEARNING RESOURCES AND MECHANISMS

Statistical Analysis
Analysis was conducted using SPSS software (version 18.0 for
Microsoft Windows, SPSS, Chicago, IL), and results were reported as
means, SDs, percentages, and minimums and maximums. t-Tests and
ANOVA were conducted to determine significant differences (32, 40).
To assess the degree to which different raters agreed in their assessment decisions, Cohens for interrater reliability was used to assess
interrater reliability (21, 43).

RESULTS

Medical Textbooks
The search ended with the identification of seven textbooks on human physiology, four textbooks on pathology,
and six textbooks on internal medicine commonly used in
teaching in undergraduate medical courses (Table 1). The 17
textbooks met the search criteria and were obtained for
further assessment. The number of chapters on cardiovascular diseases/system and blood vessels in the 17 textbooks
was 65. The percentage of cardiovascular mechanism content in physiology textbooks ranged from 5.4% [4 of 74,
Preston and Wilson (31)] to 28% [14 of 50, Mulroney and
Myers (29)], in pathology textbooks from 7.6% [4.5 of 59,
Underwood and Cross (38)] to 24.0% [24.5 of 102, Rubin et
al. (34)], and in internal medicine from 0.9% [1.5 of 152,
McPhee et al. (28)] to 10.1% [29 of 285, Longo et al. (27);
Table 1]. The overall average for cardiovascular mechanisms was 16.1% (99.5 of 618) in the seven textbooks on
physiology, 17.5% (64 of 364) in the four textbooks on
pathology, and only 6.9% (79.7 of 1,150) in the six textbooks on internal medicine. The percentage of figures committed to explain cardiovascular mechanisms in the physiology textbooks ranged from 7.2% [7 of 97, Preston and
Wilson (31)] to 30% [9 of 30, Mulroney and Myers (29)]. In
the pathology textbooks, the percentage of figures committed to cardiovascular mechanisms ranged from 5.2% [3 of
57, Underwood and Cross (38)] to 24% [12 of 50, Rubin and
Reisner (33)]. In the internal medicine textbooks, the percentage of figures committed to cardiovascular mechanisms
ranged from 0.0% [0 of 3, McPhee et al. (28)] to 9.7% [17
of 179, Longo et al. (27)].
All internal medicine textbooks except Longo et al. (27)
contained little information about cardiovascular mechanisms. For example, the textbook by McPhee et al. (28)
focused mainly on clinical findings such as symptoms,
clinical signs, investigations, differential diagnosis, treatment, and prognosis. Although the etiology of diseases was
provided, no pathophysiology or mechanisms were given.
Furthermore, no flow diagrams outlining mechanisms or the
pathogenesis of diseases were given. The textbook by Andereoli et al. (3) is a good textbook for undergraduate
medical students, but mechanisms were limited to certain
diseases. No flow diagrams outlining mechanisms or the
pathogenesis of diseases were given. The textbook by Longo
et al. (27) scored highest (10.1%) in relation to the percentage of cardiovascular mechanisms. However, more attention
to pathophysiology and mechanisms should be considered in
future editions. The three textbooks by Colledge et al. (13),
Kumar and Clark (23), and Goldman and Ausiello (18)
provided cardiovascular mechanisms at relatively reasonable percentages: 8.3%, 7.1%, and 7.0, respectively. Apart
from the textbooks by Mulroney and Myers (29), Sherwood
(35), Rubin and Reisner (33), and Widmaier et al. (42), none
of the remaining textbooks used flow diagrams to outline
mechanisms and explain the pathogenesis/pathophysiology
of cardiovascular diseases. These textbooks also limited the
mechanisms at physiological or pathological aspects with no
links to clinical symptoms, signs, or investigation results.

Advances in Physiology Education doi:10.1152/advan.00149.2013 http://advan.physiology.org

Downloaded from on December 12, 2014

decided to calculate viewership per day as a more accurate parameter

compared with total number of viewers. The viewership per day is the
ratio of number of viewers to the number of days a video is on
YouTube. The number of days was calculated from the day of
uploading on YouTube up to October 7, 2013. This calculation of
viewership per day was conducted for each video.
Evaluation tool. The criteria used for the evaluation of videos have
been described in detail in an earlier work (4, 6) with some modification to suit this study. In summary, the design of the criteria was
based on four main domains: video content, technical aspects, authority/creator, and pedagogy used. The items in the criteria were grouped
under two categories: major and minor. Major criteria comprised the
following: 1) the video uses vibrant animations or a flow diagram to
demonstrate the mechanism, 2) the contents about the mechanism are
scientifically correct, 3) the images are clear, 4) the topic is clearly
presented and is engaging, and 5) sounds are clear and the background
is free from noise. Minor criteria comprised the following: 1) the
video covers the topic identified in the title, 2) the video is designed
at the level of undergraduate medical students, 3) the time to download is reasonable (510 min at the maximum, not uninterrupted, or
there was no challenge to download as reported by the three evaluators), 4) the educational objectives are stated, and 5) the creator/or the
organization providing the video is mentioned. These criteria were
used to categorize videos into educationally useful and noneducationally useful videos. Educationally useful means that the video provides scientifically correct and up-to-date knowledge and its contents
are accepted by educators in other teaching institutes and match with
current information in the literature. As per the basis of the evaluation
criteria, educationally useful videos should fulfill the four domains:
scientific content, technical aspects, authority/creator, and pedagogy
used. Two scores were allocated for each item in major criteria, and
one score was allocated to each item under minor criteria. If an item
was fulfilled, an allocated score was given; if an item was not fulfilled,
a zero was given. No half scores were used. As per our previous
research work, educationally useful videos should fulfill all major
criteria items as the minimum requirements plus at least three items
from minor criteria (4, 6).
Piloting the evaluation. Before the tool was applied, the criteria
were piloted. A total of 20 videos (other than those identified) were
randomly selected and used for this purpose. The criteria were applied
independently by the three assessors. None of the assessors shared
their findings or discussed the outcome of their evaluation. An Excel
sheet covering the results from the three evaluations was then discussed in a meeting. Agreement among the assessors was 95%. The
findings were discussed among the researchers. The criteria items
were tested again independently by the three assessors using another
20 videos. The videos were then rated independently by the three
assessors. If videos were difficult to classify or when there was a
disagreement that arose among assessors, evaluators reviewed such
videos in a meeting and reached a final agreement.
Assessing the videos. The three evaluators independently evaluated
the videos covering the cardiovascular mechanisms. Only 29 videos
fulfilled the inclusion criteria. The data were entered using Microsoft
Excel 2010 (Microsoft, Redmond, WA) and were checked before any
analysis was conducted. Agreement between the evaluators was calculated using Cohens interrater correlation (21, 43).

Physiology

Physiology

Physiology

Physiology

Physiology

Physiology

Pathology

Pathology

Pathology

Pathology

29

15

31

10

33

34

38

24

Barrett et al.

Mulroney and
Myers

Costanzo

Preston and
Wilson

Born and
Boulpaep

Rubin and
Reisner

Rubin et al.

Underwood
and Cross

Kumar et al.

Widmaier et al.

35

42

Sherwood

Discipline

Physiology

Reference

Chapter

Advances in Physiology Education doi:10.1152/advan.00149.2013 http://advan.physiology.org

Blood vessels and
the heart (2
chapters)

Cardiovascular
system (2
chapters)

Blood vessels and

the heart (2
chapters)

Blood vessels and

the heart(2
chapters)

Cardiovascular
system (5
chapters)
Cardiovascular
system

Cardiovascular
physiology

Cardiovascular
physiology (2
chapters)
Cardiovascular
physiology (2
chapters)

Cardiac physiology

Cardiovascular
physiology

59

81

18.5

102

122

181

74

51

50

95

86

81

4.5

24.5

16.5

21

10

14

8.5

23

19

22.8

7.6

24.0

13.5

11.6

5.4

19.6

28

8.9

26.7

23.4

10 figures and 2
tables

3 figures and 0
tables

20 figures and 4
tables

12 figures and 2
tables

12 figures and 4
tables

7 figures and 0
tables

4 figures and 2
tables

9 figures and 0
tables

14 figures and 0
tables

16 figures and 2
tables

21 figures and 0
tables

Figures and
Tables on
Mechanisms

19.0 and
33.3

7.2 and 0

10 and
11.7
24 and 20

19.8 and
23.5

5.2 and 0

14.4 and
18.1

21 figures and 6
tables

97 figures and 0
tables

101 figures and

17 tables

57 figures and 8
tables

69 figures and
11 tables

50 figures and
10 tables

120 figures and

34 tables

30 and 0

30 figures and 0
tables

15.0 and 0

93 figures and
27 tables

26.5 and 0

Percentage
of
Content
Mechanism Clarity Quality Adequacy

22.8 and
22.2

70 figures and9
tables

79 figures and
15 tables

Total Figures
and Tables
Comments

Continued

A well-illustrated resource
for learning pathology.
However, mechanisms
need to be strengthened.
A well-illustrated resource
on pathology. However,
mechanisms need to be
strengthened.
The focus is on clinicpathological features.
Pathogenesis and
mechanisms are briefly
discussed.
A well-illustrated and
comprehensive textbook.
The pathogenesis of
diseases is clearly
provided, but this varied
from disease to disease.
Flow diagrams are
needed.

One of the chapters was

committed to mechanisms.

Excellent resource for

mechanisms, but there are
no integration with
pathological and clinical
aspects.
Despite the small size of the
book, mechanisms were
covered and flow
diagrams were used.
Mechanisms were not
adequately discussed.

Key mechanisms are

provided with several flow
diagrams. However,
mechanisms are not
integrated with pathology
and clinical aspects.
Excellent resource for
physiological mechanisms.
However, mechanisms are
not integrated with
pathological and clinical
aspects.
Less focus has been given to
mechanisms.

LEARNING RESOURCES AND MECHANISMS

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Authors

Percentage
Pages on
Total
of
Mechanisms Pages Mechanisms

Table 1. Summary of cardiovascular mechanisms in medical textbooks

Staying Current
127

13

28

23

27

18

McPhee et al.

Colledge et al.

Longo et al.

Andreoli et al.

Goldman and
Ausiello

Reference

Kumar and
Clark

Authors

Medicine

Medicine

Medicine

Medicine

Medicine

Medicine

Discipline

Cardiovascular disease

Cardiovascular disease
(11 chapters)

Disorders of the
cardiovascular
system (27 chapters)

Heart disease, systemic

hypertension, and
blood vessels and
lymphatic disorders
(3 chapters)
Cardiovascular disease

Cardiovascular disease

Chapter

21

29

10

1.5

9.25

297

166

285

120

152

130

7.0

5.4

10.1

8.3

0.9

7.1

Percentage
Pages on
Total
of
Mechanisms Pages Mechanisms

9 figures and 2
tables

2 figures and 1
table

17 figures and 3
tables

4 figures and 0
tables

0 figures and 0
tables

10 figures and 2
tables

Figures and
Tables on
Mechanisms

3.8 and 0

9.4 and
3.4

2.5 and
1.6

4.6 and
1.6

105 figures and

130 tables

179 figures and

86 tables

79 figures and
60 tables

195 figures and

124 tables

0 and 0

3 figures and 27
tables

7.7 and
4.0

Percentage
of
Content
Mechanism Clarity Quality Adequacy

129 figures and

49 tables

Total Figures
and Tables

A good textbook for

undergraduate students.
However, mechanisms are
limited to a few diseases.
An excellent resource for
clinical medicine.
However, mechanisms are
limited to certain diseases.
An excellent resource for
clinical medicine.
However, mechanisms are
limited to certain diseases.
Mechanisms were clearly
outlined for a number of
diseases but were brief.
No flow diagrams used.

Mechanisms for arrhythmias,

heart failure, valvular
heart diseases, and
systemic hypertension are
briefly given.
Although etiology is
provided, no
pathophysiology or
mechanisms are given.

Comments

128

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Table 1.Continued

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LEARNING RESOURCES AND MECHANISMS

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LEARNING RESOURCES AND MECHANISMS

129

eMedicine Topics

Agreement Between Assessors

A total of 48 topics from eMedicine (Medscape) on cardiovascular diseases were identified and evaluated for mechanisms (Table 2). The percentage of cardiovascular mechanism
content varied from 0% in several topics, such as alcoholic
cardiomyopathy, acute coronary syndrome, and hypertensive
heart disease, to 41.6% (2.5 of 6) for the topic on renovascular
hypertension. The overall average for the cardiovascular mechanisms in the 48 topics was 15.8% (46.2 of 292). Cardiovascular mechanisms were adequately outlined in 22.9% (11 of
48) topics, for example, atrioventricular dissociation, paroxysmal supraventricular tachycardia, premature ventricular contraction, cardiogenic pulmonary oedema, cardiogenic shock,
dilated cardiomyopathy, coronary artery atherosclerosis, heart
failure, long QT syndrome, pulmonary edema, and infective
endocarditis. In the majority of these diseases, no flow diagrams outlining the mechanisms at the body system, organ,
cellular, and molecular levels were provided. Table 2 summarizes examples of the limitations/deficiencies observed in some
of the mechanisms given.

Agreement between the three assessors was calculated using

Cohens interrater correlation. The score was in the range of
0.55 0.95 for cardiovascular mechanisms in textbooks and
Medscape. The overall score was in the range of 0.78 0.96.

A total of 1,150 YouTube videos were found on the initial

search and on applying the inclusion criteria and visual examination of the videos; only 29 videos were found relevant to
cardiovascular mechanisms (Table 3). The total duration of
these video clips was 414 min and 14 s. The application of the
criteria by the three evaluators independently revealed that
there were 16 educationally useful videos, scoring 14.1 0.5
(mean SD), and the remaining 13 videos were not educationally useful, scoring 6.1 1.72. The difference between the
two groups was significant (P 0.001).
The total duration of useful videos was 340 min and 07 s.
The total number of viewers of all videos was 274,077. The
useful videos attracted 209,597 (76.4%) of all viewers. Table 3
summarizes key information about the 29 videos included in
the study.
Except for two videos produced by a pharmaceutical company for educational purposes, all other educationally useful
videos were created by physicians and professional bodies/
institutions and were linked to organizations such as East
Carolina University, Harvard Medical School, and Brigham
and Womens Hospital, Boston, Massachusetts. The videos
addressed mechanisms of several cardiovascular diseases, including mechanisms and the pathogenesis of systolic and
diastolic heart failure, coronary artery disease, atherosclerosis,
hypertensive nephropathy, cardiac arrhythmias, and pulmonary
arterial hypertension.
The majority of noneducationally useful videos failed two of
the major criteria items (23%, 3 of 13), three items from the
major criteria (30.7%, 4 of 13), and four or more items from
the major criteria (46.1, 6 of 13). Minor criteria items were also
not fulfilled in these videos, ranging from one to three items
not fulfilled. In other words, these videos failed to provide clear
animations or flow diagrams to demonstrate the mechanism,
the topic was not clearly presented and was not engaging, and
sounds were not clear and there was noise in the background.
These videos also failed to address one or two items from the
minor criteria items.

The aim of this study was to evaluate the usefulness of

learning resources commonly used by students, including medical textbooks, eMedicine, and YouTube videos, on cardiovascular mechanisms, with particular emphasis on clarity, quality,
and percentage of content committed to cardiovascular mechanisms. 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 physiology textbooks (n 7) was 16.1% (99.5 of 618) and pathology
textbooks (n 4) was 17.5% (64 of 364), there was less
emphasis on mechanisms in most internal medicine textbooks
(n 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 consideration, 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 cardiovascular 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 adequately 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 supraventricular tachycardia, premature ventricular contraction,

Advances in Physiology Education doi:10.1152/advan.00149.2013 http://advan.physiology.org

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YouTube Videos

DISCUSSION

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Table 2. Summary of cardiovascular mechanisms in Medscape (eMedicine) topics

Pages on
Mechanisms/
Pathophysiology

Topic*

Total
Pages

Percentage
of
Mechanism

Number of Diagrams/
Tables Covering
Mechanisms

Content
Clarity

Quality

Adequacy

1
1

9
6

11.1
16.6

0
2 images and 1 ECG
tracing

2
2

2
2

2
2

Atrial tachycardia
Atrioventricular block
Atrioventricular dissociation
First-degree atrioventricular block
Long QT syndrome
Paroxysmal supraventricular tachycardia

1.5
0.5
0.5
0.5
2
3

7
5
2
4
7
8

24.2
10.0
25
12.5
28.5

0
0
0
0

3
2
3
2
3
2

3
2
3
2
3
3

2
2
3
2
3
3

Premature ventricular contraction

Second-degree atrioventricular block
Sinus bradycardia
Sudden cardiac death
Third-degree atrioventricular block
Ventricular fibrillation
Atrial tachycardia
Wolff-Parkinson-White syndrome
Coronary artery atherosclerosis

0.5
0.5
0.5
1
1.5
0.5
0.5
1.5
2

2
6
2
5
4
7
10
8
11

25
8.3
25.0
20.0
37.5
7.1
5
18.7
18.1

3
2
2
2
2
2
2
2
3

3
2
2
2
2
2
2
2
3

3
2
2
2
2
2
2
2
3

Hypertensive heart disease

16

0.0

Noncoronary atherosclerosis

14.2

Renovascular hypertension

2.5

41.6

3 images

Risk factors for coronary artery disease

0.0

1 flow diagram

Acute coronary syndrome

Angina pectoris
Coronary artery vasospasm
Myocardial infarction

0
0.5
0.5
1.5

5
5
2
10

0.0
10
25
15

0
0
0
0

2
2

2
2

2
2

Unstable angina

25

Alcoholic cardiomyopathy

0.0

Cardiogenic pulmonary edema

Cardiogenic shock
Cor pulmonale
Dilated cardiomyopathy

1
2
1
1

3
9
8
7

33.3
22.2
12.5
14.2

0
0
0
0

3
3
2
3

3
3
2
3

3
3
2
3

Heart failure

11

27.2

Hypertrophic cardiomyopathy

0.5

10.0

Restrictive cardiomyopathy
Acute pericarditis
Constrictive pericarditis
Pericardial effusion
Peripheral vascular disease
Aortic regurgitation

1
1
1
0.5
1
1

4
9
4
6
7
4

25
11.1
25
8.3
14.2
25

0
0

2
2
2
2
2
2

2
2
2
2
2
2

2
2
2
2
2
2

1 table
2 diagrams plus 11
ECG tracings
0
0
0
2 diagrams
0
0
0
0
1 diagram

1 diagram
0
0
0

The mechanism given should be

updated in light of current
publications/research.

The mechanism was clearly

explained.
The chapter focused on clinical
issues and did not address
mechanisms.
Mentioned risk factors and did
not address mechanisms.
A diagram summarizing the
mechanism would be much
better.
The discussion focused on risk
factors. The author did not
explain the underlying
mechanisms.
No mention of mechanisms.

A diagram linking risk factors

with the mechanism of
myocardial infarction is
needed.
A diagram summarizing
mechanisms is needed.
No mechanism or
pathophysiology is provided.

The mechanism is explained,

but a diagram is needed to
summarize the mechanism.
The mechanism is well
explained, but a diagram is
needed to summarize the
mechanism.
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.

Incomplete. The mechanism

given should be updated in
light of current
publications/research.

Continued
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Atrial fibrillation
Atrial flutter

Comments (Reference)

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LEARNING RESOURCES AND MECHANISMS

131

Table 2.Continued
Total
Pages

Percentage
of
Mechanism

Number of Diagrams/
Tables Covering
Mechanisms

Content
Clarity

Quality

Adequacy

Aortic stenosis
Infective endocarditis

0.5
2.5

5
11

10
22.7

0
0

2
3

2
3

2
3

Mitral regurgitation
Mitral stenosis

0.5
0.5

4
2

12.5
25

0
0

1
2

1
1

1
1

Mitral valve prolapse

0.25

8.3

Primary pulmonary hypertension

25

Pulmonary regurgitation

0.1

10

10.5

25

0.4

Topic*

Pulmonary stenosis

Rheumatic fever

5.7

Comments (Reference)
The mechanism is well
explained, but a diagram is
needed to summarize the
mechanism.
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.
No mechanism was given. The
authors discussed the natural
history of mitral valve
prolapse and myxomatous
degeneration of collagen
fibrils, etc.
Incomplete. The mechanism
given should be updated in
light of current
publications/research.
No mechanism given. The
authors briefly discussed the
causes of pulmonary
regurgitation.
Incomplete. The mechanism
given should be updated in
light of current
publications/research.
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.

cardiogenic pulmonary edema, cardiogenic shock, dilated cardiomyopathy, 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 0.05) 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 allocated more contents to mechanisms than any of the internal
medicine textbooks. However, topics varied in regard to adequacy of mechanisms, and the contents of several topics lacked
clarity and quality of information.
Despite the smaller number of educationally useful YouTube 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

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Pathophysiology

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Table 3. Details about YouTube videos discussing cardiovascular mechanisms identified in the study
Number

Title

Pathophysiology of Diastolic and

Systolic CHF
Congestive Heart Failure Epidemiology and
Pathophysiology (Part 1 of 3)
Recent insight into the
pathophysiology of heart failure
Pathophysiology of Coronary Artery
Disease
Pathophysiology of Atherosclerosis

3
4
5
6
7
8
9
10
11

13
14
15
16
17

18
19
20
21

22
23
24
25
26
27
28
29

Pathophysiology of Wolff-Parkinson
White Syndrome
Pathophysiology of Cardiac
Arrhythmias
Pathophysiology of Hypertensive
Nephropathy
Pathophysiology cardiovascular 1 of
5 Risk factors
Pathophysiology Cardiovascular 2
of 5 Peripheral artery disease
Pathophysiology cardiovascular 3 of
5 heart disease
Pathophysiology of Pulmonary
Arterial Hypertension (PAH)
Pathogenesis of the Atherosclerotic
Plaque and Acute Coronary Syn
Shotgun USMLE Renal Cardiac
Pathophysiology 1
Overview of Coronary Artery
Disease
Congestive Heart Failure Medical
Animation
Coronary Artery Disease: Cause of
Heart Attack - One Minute
Medic
Pathophysiology of CAD/MI Dr.
Milind Hanchate
Pathophysiology, Hypertension
Pathophysiology, Mitral Valve
Stenosis
Atherosclerosis (Understanding
Disease: Cardiovascular
Medicine)
How Hypertension Affects Cardiac
Risk
Pathophysiology, Myocardial
Infarction
Pathophysiology of heart failure
Pathophysiology, Heart Failure
Congestive Heart Failure
Pathophysiology, Valvular Heart
Disease
Pathophysiology of Heart Failure
Hypertension and the Mechanism of
Blood Pressure

Duration

Days on
Viewers YouTube

Viewership
per Day

Total score*

http://www.youtube.com/watch?vOwvrBVw_J4Y

21 min 18 s

38,594

465

82.9

13.67 1.52 (1215)

http://youtu.be/t4e8ucPzRjQ

55 min 7 s

7,723

414

18.6

14.67 0.57 (1415)

http://www.youtube.com/watch?vFfPUaoyARtk

30 min 50 s

57

302

0.2

13.33 1.15 (1214)

http://www.youtube.com/watch?vpXluagz53kc

20 min 10 s

22,019

465

47.3

14.33 0.57 (1415)

http://www.youtube.com/watch?vrktoF7BHRiQ&list
PL4C480876D0558842
http://www.youtube.com/watch?v_cYThiC-0uk

23 min 50 s

22,021

465

47.3

13.67 0.58 (1314)

12 min 37 s

5,052

465

10.8

13.67 0.57 (1314)

http://www.youtube.com/watch?v_50jV3DKryQ&list
PL4C480876D0558842
http://www.youtube.com/watch?vUTLCPpM2vZ8

20 min 48 s

15,000

464

32.3

13.67 0.57 (1314)

16 min 41 s

6,421

448

14.3

14.33 0.57 (1415)

http://www.youtube.com/watch?vXPzYkTjN4t4

46 min 22 s

44

60

0.7

14.00 1.00 (1315)

http://www.youtube.com/watch?vl3Pcoc3rzR4

28 min 56 s

56

183

0.3

14.33 0.57 (1415)

http://www.youtube.com/watch?vF35dTjjGy_Y

38 min 42 s

63

60

1.0

14.67 0.57 (1415)

http://www.youtube.com/watch?v9a4untSzLzg

7 min 19 s

2,305

178

12.9

14.33 0.57 (1415)

http://www.youtube.com/watch?vupb37rbS1dE

3 min 45 s

26,614

536

49.6

14.33 0.57 (1415)

http://www.youtube.com/watch?v08QUa6_zRUs

8 min 57 s

155

690

http://youtu.be/NZ14XjOQoFY

2 min 58 s

22,242

840

26.4

14.33 0.58 (1415)

http://www.youtube.com/watch?vJJAMYHAwCMs

2 min 23 s

41,231

887

46.4

13.67 0.57 (1314)

http://www.youtube.com/watch?vLmzfiA1FA-E

1 min 33 s

1,439

155

9.2

8.33 0.57 (89)

http://www.youtube.com/watch?v_pOeefZN-Wc

24 min 22 s

26

107

0.24

6.67 1.52 (58)

http://www.youtube.com/watch?v9FuSdiFRK3Y
http://www.youtube.com/watch?vVVlJX-Fd_hI

5 min 4 s
4 min 18 s

106
43

19
49

5.5
08

6.67 1.15 (68)

5.33 1.15 (46)

http://www.youtube.com/watch?v7JihvMpEP4w

2 min 48 s

36,288

628

57.7

8.67 0.57 (89)

http://www.youtube.com/watch?vjSrtyeXM59w

2 min 47 s

102

271

0.37

7.00 0.00 (77)

http://www.youtube.com/watch?vAquIpZVNc7w

2 min 36 s

340

193

1.7

5.67 1.15 (57)

http://www.youtube.com/watch?vBmkARWsZJAk
http://www.youtube.com/watch?v_IPuJvxtwqo
http://www.youtube.com/watch?vb2q672lG3Nk
http://www.youtube.com/watch?v7r4LQtACr-s

3
7
6
1

158
27
20,073
411

43
28
1605
190

3.6
0.9
12.5
2.1

3.33 0.58 (34)

6.00 1.00 (57)
7.67 1.15 (79)
5.67 1.15 (57)

http://www.youtube.com/watch?vECpGxkinwXs
http://www.youtube.com/watch?vsJop3D4YSr4

11 min 22 s
1 min 33 s

4,028
1,439

213
155

18.9
9.2

4.33 0.57 (45)

6.33 1.15 (57)

min
min
min
min

14
12
12
45

s
s
s
s

0.22

12.33 1.15 (1113)

Numbers 116 comprise educationally useful videos on cardiovascular mechanisms (n 16). Numbers 1729 comprise noneducationally useful videos on
cardiovascular mechanisms (n 13). *Total score [in means SD (minimummaximum)] 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.

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 complex 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.

Advances in Physiology Education doi:10.1152/advan.00149.2013 http://advan.physiology.org

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LEARNING RESOURCES AND MECHANISMS

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 mechanisms, despite their small number, could add useful dimensions 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.
ACKNOWLEDGMENTS
The author thanks Dr. Sarah Azer and Diana Azer for assistance and
reviewing the manuscript. The author also thanks Laniefel Mendoza (Peng)
and Mary Hadlocon for secretarial help.
GRANTS
This work was funded by the College of Medicine Research Center,
Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared by the author(s).
AUTHOR CONTRIBUTIONS
Author contributions: S.A.A. conception and design of research; S.A.A.
performed experiments; S.A.A. analyzed data; S.A.A. interpreted results of
experiments; S.A.A. prepared figures; S.A.A. drafted manuscript; S.A.A.
edited and revised manuscript; S.A.A. approved final version of manuscript.
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Advances in Physiology Education doi:10.1152/advan.00149.2013 http://advan.physiology.org

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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 parameters. The criteria system used in this study has shown its
capacity to accommodate these four parameters, and the interrater agreement among assessors had scores in the range of
0.78 0.96. Piloting the use of the criteria before their implementation 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 mechanisms 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 educationally 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 mechanisms 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 pathophysiological changes of cardiovascular diseases. Innovative ideas
that could enable learners to build mechanisms and integrate
knowledge in an engaging and interactive way are recommended. Further research is needed to assess the impact of
using learning resources demonstrating well-presented cardiovascular 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 decisionmaking skills.
In conclusion, despite the importance of mechanisms in
understanding cardiovascular diseases and in explaining the
pathophysiological changes, integrating basic and clinical sciences as well as explaining symptoms and clinical signs and
results of investigations, there was less emphasis on mechanisms in most internal medicine textbooks, and none of the
textbooks used flow diagrams to outline mechanisms or explained 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

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