How can we teach medical students to choose wisely? A randomised controlled cross-over study of video- versus text-based case scenarios

Face-to-face versus 360° VR video: a comparative study of two teaching methods in nursing education

BACKGROUND

The practical sessions during skills laboratory simulation or clinical simulation are cores of nursing education. For this, different modalities have been devised to facilitate psychomotor skills learning. One of the commonly used educational material or instructional method to supplement skills learning across various disciplines is video-based teaching method. The opportunities of traditional two-dimensional video might be limitless and maximized with 360º virtual reality (VR) video, which offers immersive experience. This study incorporates 360º VR video into skills laboratory training as an alternative approach to face-to-face procedure demonstration.

METHODS

An open-label, parallel (1:1), randomized controlled trial study was conducted among third-year undergraduate nursing students at Hiroshima University, Japan. The nursing students were block-randomized into 360º VR video and face-to-face demonstration group. After a 3-hour theoretical class of patient management on ventilator and closed-suction principles of mechanically ventilated patients in an Intensive Care Unit focused class, the 360º VR group watched the 360º VR video of closed tracheal suction (including oral) using the head-mounted display of Meta Quest 2 individually, while the face-to-face group attended the instructor's demonstration. A week after the skills laboratory, the students' psychomotor skills, knowledge, satisfaction, confidence were evaluated; the 360º VR video group's perception was explored; Wilcoxon rank-sum test was used to compare the two groups.

RESULTS

A total of 57 students were analyzed; 27 students in the 360º VR video group and 30 students in face-to-face group. There were no statistically significant differences between both groups in skills, knowledge, and confidence. However, the face-to-face group had higher satisfaction level than the 360º VR group; this difference was statistically significant. In the 360º VR video group, 62% agreed that VR makes learning more interesting; more than half of students (62.5%) experienced VR sickness symptoms, and "feeling of drunk" is the highest. The students appreciated the ready to use, immersiveness, and realism; however, symptoms and discomfort, burdensomeness, and production limitations were improvements recommended.

CONCLUSION

Although face-to-face demonstration is the established method of teaching psychomotor skills to nursing students, the use of 360º VR video could achieve similar learning effect as an alternative approach.

Patient video cases in large-group medical student teaching: A qualitative study of learner and educator perspectives

BACKGROUND

Patient video cases (PVCs) are short video recordings of real patients during clinical encounters or instructed activities. Although widely used in healthcare professionals' education, their use in large group teaching (LGT) remains relatively unexplored. This study aims to explore the perceptions of medical students and academic staff regarding the use of PVCs to support LGT.

METHODS

A purposive sample of medical students and academic staff from Leicester Medical School was obtained. Data were collected through focus groups (students) and semi-structured interviews (staff) in which two sensitising PVCs were used as a stimulus to discussion. Data analysis was undertaken using grounded theory through a process of open, axial, and selective coding, leading to core categories and themes.

RESULTS

Sixteen medical students and four academic staff members participated. Four overarching themes were identified covering the benefits of using PVCs, ways in which they are used in LGT, the challenges faced by and how to optimise PVCs for LGT. This final theme covered design, choice of clip and how it is then used by the educator within the teaching session. Key considerations were the need to align the PVC with other content and to consider the student experience.

CONCLUSION

Our findings support the use of well-chosen and well-designed PVCs within LGT and offer practical insights to use them effectively. PVCs are a potentially powerful tool within medical undergraduate LGT (a widely used instructional method) and further research into its use is needed.

Effects of Elaboration and Instructor Feedback on Retention of Clinical Reasoning Competence Among Undergraduate Medical Students: A Randomized Crossover Trial

This randomized crossover trial examines whether elaboration on common errors in patient treatment, combined with individualized mailed feedback, improves medium-term retention of clinical reasoning competence.

Authentic learning in healthcare education: A systematic review

BACKGROUND

The increasing complexity of the clinical environment demands a higher level of clinical performance competency. New pedagogical authentic learning methods have been developed to meet this need by bridging the gap between knowledge and practice.

OBJECTIVE

This systematic review aimed to examine authentic learning methods and their effects in healthcare education.

DESIGN

Systematic review.

DATA SOURCES

Data were obtained from a literature search of Embase, PubMed, MEDLINE, CINAHL, PsycINFO, and Korean databases (e.g., KoreaMed) for studies published until May 2021. This review selected research papers documenting RCTs or quasi-experimental studies targeting undergraduate students training to become healthcare professionals.

REVIEW METHODS

This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. The risk of bias assessment utilized the Joanna Briggs Institute (JBI) critical checklist.

RESULTS

Of 20 selected studies, 12 studies were randomized controlled trials, while 8 had quasi-experimental designs with a control group. Simulation was identified as an effective educational method for authentic learning. Through authentic learning, undergraduate students cultivated their knowledge and learning motivation. However, divergent conclusions were shown for performance skills.

CONCLUSIONS

Authentic pedagogical methodologies effectively enhanced learners' competencies in the cognitive, psychomotor, and affective domains. Integrating technological applications, e.g., e-learning or web-based approaches, facilitated education across academic boundaries. Further studies on combining technology with authentic learning approaches should be conducted to construct realistic educational environments for learners.

TRIAL REGISTRATION

CRD42021229350.

Using item response theory to appraise key feature examinations for clinical reasoning

BACKGROUND

Validation of examinations is usually based on classical test theory. In this study, we analysed a key feature examination according to item response theory and compared the results with those of a classical test theory approach.

METHODS

Over the course of five years, 805 fourth-year undergraduate students took a key feature examination on general medicine consisting of 30 items. Analyses were run according to a classical test theory approach as well as using item response theory. Classical test theory analyses are reported as item difficulty, discriminatory power, and Cronbach's alpha while item response theory analyses are presented as item characteristics curves, item information curves and a test information function.

RESULTS

According to classical test theory findings, the examination was labelled as easy. Analyses according to item response theory more specifically indicated that the examination was most suited to identify struggling students. Furthermore, the analysis allowed for adapting the examination to specific ability ranges by removing items, as well as comparing multiple samples with varying ability ranges.

CONCLUSIONS

Item response theory analyses revealed results not yielded by classical test theory. Thus, both approaches should be routinely combined to increase the information yield of examination data.

Use of digital teaching resources and predictors of medical student performance during the pandemic: A prospective study

Background

The coronavirus pandemic has led to increased use of digital teaching formats in medical education. A number of studies have assessed student satisfaction with these resources. However, there is a lack of studies investigating changes in student performance following the switch from contact to virtual teaching. Specifically, there are no studies linking student use of digital resources to learning outcome and examining predictors of failure.

Methods

Student performance before (winter term 2019/20: contact teaching) and during (summer term 2020: no contact teaching) the pandemic was compared prospectively in a cohort of 162 medical students enrolled in the clinical phase of a five-year undergraduate curriculum. Use of and performance in various digital resources (case-based teaching in a modified flipped classroom approach; formative key feature examinations of clinical reasoning; daily multiple choice quizzes) was recorded in summer 2020. Student scores in summative examinations were compared to examination scores in the previous term. Associations between student characteristics, resource use and summative examination results were used to identify predictors of performance.

Results

Not all students made complete use of the digital learning resources provided. Timely completion of tasks was associated with superior performance compared to delayed completion. Female students scored significantly fewer points in formative key feature examinations and digital quizzes. Overall, higher rankings within the student cohort (according to summative exams) in winter term 2019/20 as well as male gender predicted summative exam performance in summer 2020. Scores achieved in the first formative key feature examination predicted summative end-of-module exam scores.

Conclusions

The association between timely completion of tasks as well as early performance in a module and summative exams might help to identify students at risk and offering help early on. The unexpected gender difference requires further study to determine whether the shift to a digital-only curriculum disadvantages female students.

Teaching medical students to choose wisely through simulation

The Choosing Wisely (CW) campaign aims to encourage dialog among physicians and patients about the costs and benefits of medical care. The purpose of the present study was to describe the implementation of the CW campaign among medical students in the pediatrics clerkship using different teaching strategies and to evaluate the students' perception and performance. A prospective, interventionist, open study with a control group was conducted. All sixth-year undergraduate medical students that were on their pediatric clerkship at the Emergency Department during the study period were invited to participate. The study consisted of two strategies: a remote video class about the CW initiative and in situ simulation training. By the end of the rotation, all participants were evaluated through an Objective Structured Clinical Examination (OSCE). A total of 50 students were included, of which 24 watched only the online video (control group) and 26 were exposed to both the online video and the simulation scenarios (intervention group). Students in the intervention group had a significantly higher total score in the OSCE compared to students in the control group (median 90 vs 90; range 78-100 vs 50-100; p: 0.047). Median scores of behavioral items of the OSCE grouped together were significantly higher in the intervention group compared to the control group (median 60 vs 50; range 40-60 vs 20-60; p: 0.002).Conclusion: Simulation training about principles of the CW campaign had a greater impact on behavioral aspects of undergraduate students. This learning strategy was well accepted by participants. What is Known: • The Choosing Wisely (CW) campaign aims to encourage dialog among physicians and patients about the costs and benefits of medical care. • Teaching high-value and cost-conscious care to medical students is highly desired.. What is New: • Simulation training about principles of the CW campaign had a greater impact on behavioral aspects of undergraduate students.

Use of 360° virtual reality video in medical obstetrical education: a quasi-experimental design

BACKGROUND

Video-based teaching has been part of medical education for some time but 360° videos using a virtual reality (VR) device are a new medium that offer extended possibilities. We investigated whether adding a 360° VR video to the internship curriculum leads to an improvement of long-term recall of specific knowledge on a gentle Caesarean Sections (gCS) and on general obstetric knowledge.

METHODS

Two weeks prior to their Obstetrics and Gynaecology (O&G) internship, medical students were divided in teaching groups, that did or did not have access to a VR-video of a gCS. Six weeks after their O&G internship, potentially having observed one or multiple real-life CSs, knowledge on the gCS was assessed with an open questionnaire, and knowledge on general obstetrics with a multiple-choice questionnaire. Furthermore we assessed experienced anxiety during in-person attendance of CSs, and we asked whether the interns would have wanted to attend more CSs in-person. The 360° VR video group was questioned about their experience directly after they watched the video. We used linear regression analyses to determine significant effects on outcomes.

RESULTS

A total of 89 medical students participated, 41 in the 360° VR video group and 48 in the conventional study group. Watching the 360° VR video did not result in a difference in either specific or general knowledge retention between the intervention group and the conventional study group. This was both true for the grade received for the internship, the open-ended questions as well as the multiple-choice questions and this did not change after adjustment for confounding factors. Still, 83.4% of the 360° VR video-group reported that more videos should be used in training to prepare for surgical procedures. In the 360° VR video-group 56.7% reported side effects like nausea or dizziness. After adjustment for the number of attended CSs during the practical internship, students in the 360° VR video-group stated less often (p = 0.04) that they would have liked to attend more CSs in-person as compared to the conventional study group.

CONCLUSION

Even though the use of 360° VR video did not increase knowledge, it did offer a potential alternative for attending a CS in-person and a new way to prepare the students for their first operating room experiences.

Choosing Wisely: Determining performance of unjustified imaging in a large healthcare system

AIMS

The Choosing Wisely Campaign identifies procedures and treatments that lack clinical justification for routine use according to expert opinion and evidence-based medicine. This study describes the rates and features of two such examples over a 10-year period.

METHODS

This is a cross-sectional rolling cohort study between 2008 and 2017 in Clalit Health Services, the largest healthcare delivery system in Israel, with seven main hospitals and over 4.5 million members nationwide. All adult members who visited a Clalit Emergency Department (ED), and all children members who visited a Clalit ED for abdominal pain or appendicitis were eligible to be included in this study. Our measures were routine chest radiograph (CXR) in the context of pre-admission assessment for adults and abdominal computed tomography (CT) to rule out appendicitis for children.

RESULTS

Of the 3 689 869 adult visits without a clinical indication for a CXR, 9.1% or 337 058 of them received a chest radiograph. Of the 35 973 children visits for presumed appendicitis, 7.2% of them had no imaging performed, 82.3% had an ultrasound (US), 6.9% had an US followed by a CT, and 3.6% or 1293 of them received a CT. There were several independent risk factors such as BMI, hospital, sex, year and diagnosis that are associated with having imaging that is not clinically indicated.

CONCLUSIONS

Overall, this study found that diagnostic imaging practices are applied inconsistently by hospital and by population. Intervention efforts should be focused on subpopulations at greatest risk to further reduce exposure to such imaging.

Design and Implementation of a Peer-Reviewed Medical Education Video Competition: The Best of American Thoracic Society Video Lecture Series

BACKGROUND

Video is an increasingly popular medium for consuming online content, and video-based education is effective for knowledge acquisition and development of technical skills. Despite the increased interest in and use of video in medical education, there remains a need to develop accurate and trusted collections of peer-reviewed videos for medical learners.

OBJECTIVE

We developed the first professional society-based, open-access library of crowd-sourced and peer-reviewed educational videos for medical learners and health care providers.

METHODS

A comprehensive peer-review process of medical education videos was designed, implemented, reviewed, and modified using a plan-do-study-act approach to ensure optimal accuracy and effective pedagogy, while emphasizing modern teaching methods and brevity. The number of submissions and views were tracked as metrics of interest and engagement of medical learners and educators.

RESULTS

The Best of American Thoracic Society Video Lecture Series (BAVLS) was launched in 2016. Total video submissions for 2016, 2017, and 2018 were 26, 55, and 52, respectively. Revisions to the video peer-review process were made after each submission cycle. By 2017, the total views of BAVLS videos on www.thoracic.org and YouTube were 9100 and 17 499, respectively. By 2018, total views were 77 720 and 152 941, respectively. BAVLS has achieved global reach, with views from 89 countries.

CONCLUSIONS

The growth in submissions, content diversity, and viewership of BAVLS is a result of an intentional and evolving review process that emphasizes creativity and innovation in video-based pedagogy. BAVLS can serve as an example for developing institutional or society-based video platforms.

The Impact of Medical Students' Individual Teaching Format Choice on the Learning Outcome Related to Clinical Reasoning

BACKGROUND

Repeated formative assessments using key feature questions have been shown to enhance clinical reasoning. Key feature questions augmented by videos presenting clinical vignettes may be more effective than text-based questions, especially in a setting where medical students are free to choose the format they would like to work with. This study investigated learning outcomes related to clinical reasoning in students using video- or text-based key feature questions according to their individual preferences.

OBJECTIVE

The aim of this study was to test the hypothesis that repeated exposure to video-based key feature questions enhances clinical reasoning to a greater extent than repeated exposure to text-based key feature questions if students are allowed to choose between those different formats on their own.

METHODS

In this monocentric, prospective, nonrandomized trial, fourth-year medical students attended 12 computer-based case seminars during which they worked on case histories containing key feature questions. Cases were available in a text- and a video-based format. Students chose their preferred presentation format at the beginning of each case seminar. Student performance in key feature questions was assessed in formative entry, exit, and retention exams and was analyzed with regard to preceding exposure to video- or text-based case histories.

RESULTS

Of 102 eligible students, 75 provided written consent and complete data at all study exams (response rate=73.5%). A majority of students (n=52) predominantly chose the text-based format. Compared with these, students preferring the video-based format achieved a nonsignificantly higher score in the exit exam (mean 76.2% [SD 12.6] vs 70.0% [SD 19.0]; P=.15) and a significantly higher score in the retention exam (mean 75.3% [SD 16.6] vs 63.4% [SD 20.3]; P=.02). The effect was independent of the video- or text-based presentation format, which was set as default in the respective exams.

CONCLUSIONS

Despite students' overall preference for text-based case histories, the learning outcome with regard to clinical reasoning was higher in students with higher exposure to video-based items. Time-on-task is one conceivable explanation for these effects as working with video-based items was more time-consuming. The baseline performance levels of students do not account for the results as the preceding summative exam results were comparable across the 2 groups. Given that a substantial number of students chose a presentation format that was less effective, students might need to be briefed about the beneficial effects of using video-based case histories to be able to make informed choices about their study methods.

The Case of Ty Jackson: An Interactive Module on LGBT Health Employing Introspective Techniques and Video-Based Case Discussion

Introduction

The Institute of Medicine's 2011 report on lesbian, gay, bisexual, and transgender (LGBT) health and the legalization of same-sex marriage are just two of the numerous milestones that have hastened medical schools' efforts to prepare trainees to address the needs of LGBT community members. Early awareness of sexual diversity through self- and peer introspection and video-based education can help trainees build a foundation towards providing affirming care to LGBT patients.

Methods

The Kern model was used to develop, implement, and evaluate an interactive multimodal workshop to provide first-year medical students with a formative introduction to LGBT health. Learning objectives focused on comprehending the spectrum of human sexuality, health issues for LGBT patients, and better practices for promoting affirming care. The module consisted of a PowerPoint presentation, sexuality survey, videos of provider-patient encounters, and community-based resources.

Results

The workshop was implemented among 178 first-year medical students in September 2018, with 93% completing the pre-/postworkshop evaluations. Comparison of evaluations showed an increase in confidence in addressing each of the three learning objectives. Over 85% rated the PowerPoint and videos as very good or excellent.

Discussion

This workshop was effective in helping first-year medical students appreciate the spectrum of sexual diversity, health issues facing LGBT individuals, and better practices to promote affirming care. The real-time sexuality survey helped trainees appreciate sexual diversity through self-reflection and near-peer sharing. The videos and accompanying discussion provided real-life encounters, along with common pitfalls in and pearls for communicating with LGBT patients.

Perception of health-related case studies in the context of introduction to clinical medicine course: students' and teachers' perspective

BACKGROUND

Integrating theoretical and practical knowledge and stimulating students' active learning is the most important task of modern and high-quality healthcare education. By analyzing clinical cases, undergraduate medical students are trained to make accurate diagnoses, to choose appropriate therapy based on laboratory results and on adequate diagnostic tests.

AIM

To examine the effect of clinical cases presentations on short-term memory as well as on the student's and teachers' evaluation of this method of teaching and learning in undergraduate medical studies.

METHODS

A total of 107 students in term 4 and term 5 enrolled in Trinity Medical Sciences University in St. Vincent and the Grenadines participated in this cross-sectional study. At the end of the semester, the students and the faculty were asked to complete a survey to assess their perception of case presentations (10 items, 4-point Likert-type scale, strongly agree to strongly disagree). The results of pre- and post-presentation quizzes were evaluated using the Wilcoxon signed rank test for paired samples.

RESULTS

Term 4 and term 5 students significantly improved their achievement after intervention (Wilcoxon test Z = - 11.282, p < 0.001, and Wilcoxon test Z = - 10.167, p < 0.001, respectively). The analysis of progress among low- and high-performance students in both terms showed a significant increase in performance. Overall, median students' and teachers' attitude scores were positive.

CONCLUSION

Clinical case presentation has a learning potential and facilitates positive interaction between instructors and students and supporting students to become reflective and competent physicians.

Quality Principles of App Description Texts and Their Significance in Deciding to Use Health Apps as Assessed by Medical Students: Survey Study

Background

Currently, there are no binding requirements for manufacturers prescribing which information must be included in the app descriptions of health apps.

Objective

The aim of this study was to investigate how medical students perceive a selection of quality principles, intended for usage decisions in the app context, and establish whether the information presented in a sample of app descriptions is perceived as sufficient for facilitating an informed usage decision.

Methods

A total of 123 students (mean age 24.2 years, SD 3.4) participating in a 6-week teaching module covering cardiology and pulmonology at the University of Göttingen (original enrollment 152 students, response rate 80.9%) were included. Students were asked to read 3 store description texts of cardiological or pneumological apps and initially assess whether the descriptions sufficed for a usage decision. Subsequently, they were queried on their perception of the relevance of 9 predefined quality principles, formulated for usage decisions. An appraisal of whether the app description texts contained sufficient information to satisfy these quality principles followed. By means of 20 guiding questions, participants were then asked to identify relevant information (or a lack thereof) within the descriptions. A reassessment of whether the description texts sufficed for making a usage decision ensued. A total of 343 complete datasets were obtained.

Results

A majority of the quality principles were described as “very important” and “important” for making a usage decision. When accessed via the predefined principles, students felt unable to identify sufficient information within the app descriptions in 68.81% (2124/3087) of cases. Notably, information regarding undesired effects (91.8%, 315/343), ethical soundness (90.1%, 309/343), measures taken to avert risks (89.2%, 306/343), conflicts of interest (88.3%, 303/343), and the location of data storage (87.8%, 301/343) was lacking. Following participants’ engagement with the quality principles, statistically significant changes in their assessment of whether the app descriptions sufficed for a usage decision can be seen—McNemar-Bowker test (3)=45.803919, P<.001, Cohen g=.295. In 34.1% (117/343) cases, the assessment was revised. About 3 quarters of changed assessments were seen more critically (76.9%, 90/117). Although, initially, 70% (240/343) had been considered “sufficient,” this rate was reduced to 54.2% (186/343) in the second assessment.

Conclusions

In a considerable number of app descriptions, participants were unable to locate the information necessary for making an informed usage decision. Participants’ sensitization to the quality principles led to changes in their assessment of app descriptions as a tool for usage decisions. Better transparency in app descriptions released by manufacturers and the exposure of users to quality principles could collectively form the basis for well-founded usage decisions.

Training of clinical reasoning with a Serious Game versus small-group problem-based learning: A prospective study

INTRODUCTION

Serious Games are increasingly being used in undergraduate medical education. They are usually intended to enhance learning with a focus on knowledge acquisition and skills development. According to the current literature, few studies have assessed their effectiveness regarding clinical reasoning (CR). The aim of this prospective study was to compare a Serious Game, the virtual Accident & Emergency department 'EMERGE' to small-group problem-based learning (PBL) regarding student learning outcome on clinical reasoning in the short term.

METHODS

A total of 112 final-year medical students self-selected to participate in ten 90-minute sessions of either small-group PBL or playing EMERGE. CR was assessed in a formative examination consisting of six key feature cases and a final 45-minute EMERGE session.

RESULTS

Overall, the EMERGE group (n = 78) scored significantly higher than the PBL group (n = 34) in the key feature examination (62.5 (IQR: 17.7)% vs. 54.2 (IQR: 21.9)%; p = 0.015). There was no significant difference in performance levels between groups regarding those cases which had been discussed in both instructional formats during the training phase. In the final EMERGE session, the EMERGE group achieved significantly better results than the PBL group in all four cases regarding the total score as well as in three of four cases regarding the final diagnosis and the correct therapeutic interventions.

CONCLUSION

EMERGE can be used effectively for CR training in undergraduate medical education. The difference in key feature exam scores was driven by additional exposure to more cases in EMERGE compared to PBL despite identical learning time in both instructional formats. EMERGE is a potential alternative to intensive small-group teaching. Further work is needed to establish how Serious Games enhance CR most effectively.