The Effectiveness of Digital vs. Analogue Teaching Resources in a Flipped Classroom for Undergraduate Focus Cardiac Ultrasound Training: A Prospective, Randomised, Controlled Single-Centre Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript compared the effectiveness of e-learning versus traditional teaching in medical education of ultrasound in a one-day Focused Cardiac Ultrasound (FoCUS) course for third-year medical students. In a randomized controlled trial, one group used e-learning materials while the other used printed lecture notes, with both groups following a inverted classroom format. Assessments were conducted at three stages using surveys, theory tests, and practical exams (DOPS). Despite less practice time, the e-learning group performed significantly better in one practical exam and showed skill improvement comparable to the control group overall. Both groups rated the course and materials positively. The study concludes that e-learning is equally effective as traditional methods and supports its use in medical education.

This study highlights the important role of ultrasound in clinical diagnostics. Ultrasound education in medical school is still non-standard which is seen frequently in early residency training. On the other hand, there is not much more time available for additional courses in medical school training and efficient ways to teach important clinical skills within already overloaded curricula is challenging. Therefore, the research idea is very compelling. Study design is clear and seems good to answer the research question. Presentation of results is appropiate and well-structured. Literature research and discussion was done meticously and seems appropiate. 

Author Response

We sincerely thank the reviewer for their thorough and constructive feedback. All comments and suggestions have been carefully addressed and are outlined in detail in the attached point-by-point response. Should any questions remain, we are happy to provide further clarification at any time.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

General Comment

 

This manuscript presents a valid and timely contribution to medical education research. The use of a prospective, randomized, controlled design to compare digital and analogue resources in a flipped classroom format for undergraduate Focused Cardiac Ultrasound (FoCUS) training is highly relevant, especially in the context of post-pandemic digital transformation in teaching.

 

While the study is methodologically thoughtful and the manuscript is generally well-written, several issues require clarification or revision. Definitions are occasionally imprecise, and the authors draw conclusions that are somewhat stronger than the data can support. Nevertheless, the quality of the work is high, and the study is a meaningful addition to the literature.

 

I recommend publication following minor revisions as outlined below.

 

1. Language and Terminology Corrections

Abstract:

Line 7: "centring" should read “centering on”.

 

Line 8: Add “undergraduate” before “medical students” for clarity.

Line 20: Clearly identify the control group in the context of comparative outcomes.

 

Lines 21–22: Clarify comparisons between which groups (i.e., e-learning vs. script).

Reduce the conclusion: The results don’t necessarily necessitate  increases quality assurance-->  It suggests that accreditation can be done similarly to traditional learning methods, without the necessity of on site- face to face interaction as a qualitative criterion.

 

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Line 110: Grammar correction: “having passed” instead of “passed”.

 

Line 163: Clarify that sociodemographic data were collected but not evaluated.

 

Line 327: Please ensure consistent and precise use of “competence” vs. “competency.” Competency is typically used to describe discrete skills and behaviors.

Incoherent use of wording:

“In essence, competence refers to the overall ability to do something well, while competency focuses on the specific knowledge, skills, and behaviors that contribute to that ability.”

 

2. Introduction

 

The definition of the flipped classroom is incomplete. It should note that this approach changes the role of the educator from a lecturer to a facilitator or guide. This conceptual shift is central to flipped learning models and should be discussed .

 

3. Methods

 

Recruitment: Clarify the academic level (undergraduate, third-year medical students) and the context (voluntary, extracurricular). This is critical for international readers and interpretation of the motivation data, as they may not be fully aware of the role of a students affairs office or just 3rd year students? (maybe introduce an abreviation, so it doesn't need to come up so many times ( 3rd year)

 

Randomization: Please describe the randomization method (e.g., block, stratified).

 

Line 160: Define the consensus process used to design evaluation tools—was this a Delphi approach or another consensus methodology?

 

Psychometrics: Specify which tools were used to measure motivation and self-efficacy. If no validated instruments were used, explain how constructs were operationalized and why.

 

Learning Objectives: Clarify what is meant by having students comment on the learning objectives. These are typically predefined by curriculum designers.

 

Pseudonymization: Provide a brief description of how data were linked and anonymized.

 

Ethical Approval: The ethics committee reference is missing. It ought to be stated explicitly, or an exception stated.

 

4. Results and Statistical Reporting

 

 

 

Exclusions: Address why so many participants were excluded from the final analysis (Figure 2). Clarify whether exclusion criteria were applied symmetrically.

 

Practice Time: Acknowledge that the 15% reduction in practice time is an artificial construct; differences in learning media engagement should be considered in interpreting efficacy.

 

5. Discussion

 

Conclusion Overreach: Several conclusions go beyond the limits of the dataset:

 

Line 358–361:

 

“This finding emphasizes the importance of strong foundational knowledge of imaging techniques...”

This cannot be firmly concluded from a voluntary, short-format undergraduate course.

 

Line 365–366:

 

“This observation supports the theory that learners who independently manage their learning processes…”

This could be discussed more cautiously and framed in the context of autonomous motivation, ideally referencing Ryan & Deci's Self-Determination Theory.

 

Certification Claim: The study does not warrant a call for standardized certification of e-learning modules (line 26, 395–401). At best, it suggests parity in outcome within a controlled, short-term training format.

 

E-learning Technology Speculation: The discussion on future use of VR/AR/AI (lines 385–391) should be shortened or removed unless supported by data or referenced literature.

 

Motivation Bias: A major limitation is voluntary participation, attracting intrinsically motivated students. Literature suggests such students comprise only ~15% of cohorts in years 3–5 in Germany. This is crucial when interpreting motivation, satisfaction, and performance outcomes.

 

6. Conclusion

 

Reduce strength of claims:

 

“This study demonstrates that e-learning is an effective method…” → Suggest:

“This study suggests that e-learning is a viable method for content delivery in flipped classroom settings, producing similar outcomes to traditional methods in this specific context.”

 

Avoid implying generalizability or long-term clinical translation of these results.

 

7. Final Notes

 

The manuscript is well-structured and the tables/figures are informative.

 

Shorten the discussion to focus on results directly supported by the study.

 

Cite relevant literature on motivation, digital learning theory, and flipped classroom pedagogy as needed (e.g.,  Ryan & Deci).

 

Recommendation

 

Minor Revision – I commend the authors for their rigorous and relevant study. With the recommended clarifications and adjustments, the manuscript will offer a valuable contribution to medical education literature.

Author Response

We sincerely thank the reviewer for their thorough and constructive feedback. All comments and suggestions have been carefully addressed and are outlined in detail in the attached point-by-point response. Should any questions remain, we are happy to provide further clarification at any time.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This study is evaluating the effectiveness of e-learning versus analogue resources in the context of ultrasound education for undergraduate medical students.The paper addresses an important and evolving area of medical education, particularly in light of the post-COVID-19 digital transformation in teaching.

Here come my comments and suggestions:

• While the study provides important insights into teaching methods for cardiac ultrasound, its single-centre design raises concerns about generalizability. The authors do acknowledge this as a limitation; however, more context is needed regarding the institutional setting. (e.g., available infrastructure, student digital literacy) as this would strengthen the interpretation.

 

• The study effectively demonstrates that both teaching methods are comparably effective in the short term, but it does not explore retention of knowledge or long-term skill sustainability which is a critical consideration for clinical competence. Adding a comment in the discussion regarding the need for longitudinal follow-up would strengthen the conclusions and underscore the importance of durability in educational interventions.

 

• While supplementary materials describe the digital and analogue resources, the main text would benefit from a more concise, side-by-side summary of the key features of each intervention. For example: topics or content types were included (text, images, videos, interactive quizzes), students’ interaction with each format (e.g., passive reading vs. active clicking or self-testing), the estimated time requirement for engaging with each type of material. This would help clarify the pedagogical differences beyond the mode of delivery and would allow a more nuanced discussion of why the e-learning group may have demonstrated comparable or superior outcomes despite reduced practice time.

 

 

• The intentional 15% reduction in hands-on practice for the e-learning group is an interesting aspect of the study but deserves further scrutiny:
• While the goal was to test learning efficiency, reducing practice time introduces a confounding variable when comparing learning outcomes between groups.
• The authors could better justify this design choice in the methods section and discuss whether the observed learning equivalence might have been different if practice time were equal.

 

• The study relies on self-reported motivation, competence, and satisfaction, which are inherently subjective and susceptible to bias for example, students who are more digitally literate or enthusiastic about technology may report higher satisfaction regardless of actual learning gains. Consider discussing this potential bias more deeply.

 

• The manuscript is generally well-written, but several points of language and terminology could be standardized or clarified:
• The term “script” should be replaced throughout with “lecture notes”.
• Abbreviations such as FoCUS, DOPS, and TU should be spelled out at first use in each major section (abstract, methods, results).

Author Response

We sincerely thank the reviewer for their thorough and constructive feedback. All comments and suggestions have been carefully addressed and are outlined in detail in the attached point-by-point response. Should any questions remain, we are happy to provide further clarification at any time.

Author Response File: Author Response.pdf