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Increasing medical student interaction: The radiology passport
Radiologic E d u c a t i o n and T e a c h i n g Research Robert A. Novelline, MD, Editor
Increasing Medical Student Interaction: The Radiology Passport Gary L. Merhar, MD
Rationale and Objectives. A pocket-sized booklet and learning aid, the "Radiology Passport," was introduced into the radiology clerkship. A study was devised to assess the effectiveness of the Radiology Passport on the clinical interaction of junior medical students during their required 2-week clerkship. Methods. The Radiology Passport contained the student's identification picture and a list of teaching points to be learned in each subspecialty station area. The Radiology Passport was given to alternating groups of junior medical students to be carried during their 2week clerkship. All students were given a pre- and posttest with questions relating specifically to the clinical stations. In addition, results of a standardized course evaluation designed by the dean's office of the medical school were analyzed. The groups with and without Radiology Passports were then compared. Results. The groups carrying the Radiology Passports had significant improvement on their posttest scores compared with the nonpassport group. In addition, there was a significant increase in the perceived interaction with residents and faculty, instructor feedback, the overall quality of learning, and the amount of time the students actually spent in the department over the 2 weeks. Conclusion. The Radiology Passport is an easy, inexpensive learning aid that improves the quality of education and clinical interaction during the radiology clerkship. Key Words. Education; medical students; radiology learning; teaching model.
he radiology clerkship at the University of Cincin-
T nati College of Medicine is a required course in the
junior year. The radiology clerkship is 2 weeks in length with four to eight students per session. The University Hospital is the only teaching site for the junior radiology clerkship. A senior clerkship is 4 weeks in length and is run separately. The daily schedule for the junior clerkship includes a plain film interpretation session with faculty, clinical interaction at workstations throughout the department, a small peer-group film interpretation session, a lunchtime departmentwide conference, and a clinical problem-solving lecture given by faculty. Fundamentals of Radiology by Lucy Frank Squire and Robert Novelline is the required text [1]. For years the weakest part of the clerkship has been the clinical interaction of the students in the department. The students have complained about the poor teaching by residents and the inability to learn radiology in the clinical setting. The lack of interest shown to students has caused daily attendance to suffer. Keeping track of clinical attendance has proven to be logistically impossible. Because our department feels strongly that this clinical time is important to the students' radiology education, a simple teaching tool, the Radiology Passport, was developed. Each page of the passport contains five teaching points for each of nine clinical areas. These teaching points have been submitted by the department section heads. The students are at the clinical stations for 3 hr per
From the Department of Radiology, University Hospital, Cincinnati, OH.
Address reprint requests to G. L. Merhar, MD, Department of Radiology, University Hospital, 234 Goodman St., Cincinnati, OH 45267-0742. Received February 16, 1994, and accepted for publication after revision November 22, 1994. Acad Radio11995;2:345-350 © 1995, Association of University Radiologists
345
MERHAR
day and rotate to a new station daily. At the end of their scheduled clinical time, a resident, fellow, or staff assigned to the clinical station signs the medical student's passport, indicating that the student learned the five teaching points. The students turn in their passports to the course director at the end of their clerkship. To test the hypothesis that the passport improved clinical interaction and learning, only alternating 2w e e k groups were given the passport. The nonpassport group otherwise had an identical experience. Both groups were given identical pre- and posttests designed to test their observations at the clinical stations. At the end of the course, a standard questionnaire was filled out by the students. This questionnaire was designed by the dean's office to help in assessing all clerkships. We c o m p a r e d the results of the pre- and posttests and questionnaires of the passport and nonpassport groups.
Vol. 2, No. 4, April 1995
A
MATERIALS AND METHODS Mtemating groups of third-year medical students were given Radiology Passports. The passport is a pocket-sized booklet designed to look like a U.S. passport and contains the student's identification photograph and signature (Fig. 1). It contains a list of teaching points divided by clinical sections and a space for the resident or faculty to sign (Fig. 2). The students carried these passports to the nine clinical stations, which were abdominal imaging, gastrointestinal fluoroscopy, neuroradiology, pediatric radiology (at the Cincinnati Childrens' Hospital), nuclear medicine, emergency radiology, chest radiology, sonography, and orthopedic radiology. Groups without passports were given the same clinical assignments. A list of the teaching points was available at each clinical area so that the nonpassport group might have the same opportunity to learn. A multiple-choice test with 40 questions related to the teaching points was given to all students immediately after they assembled in the radiology department on the first day. The identical test was given on the final day of the clerkship. Sample questions are listed in Table 1. A standard questionnaire was filled out by both groups at the time of the final written examination on the last day of the course. The questionnaire asked the students to grade various attributes of the clerkship on a scale of 1 to 5. Table 2 illustrates a sample questionnaire.
Analysis The test scores and questionnaire results were entered into a database, and statistical analysis of the results of the two groups was performed using Statistical Package for the Social Sciences (SPSS) for Windows, Volume 6 346
B FIGURE 1. A and B, The "Radiology Passport" cover (A) and student ID photograph and signature (B).
(SPSS, Chicago, IL). The differences in pre- and posttest results were compared using the paired t test. Course evaluation questions were compared using t tests for independent samples. Levene's test for equality of variances was used to choose between p values to ensure comparable variances between samples. Because not all questions On the evaluation were answered by all the students, the n values for some variables differed.
Vol. 2, No. 4, April 1995
MEDICAL STUDENT INTERACTION TABLE 1: Sample Pre- and Posttest Questions Based on Points Learned at Clinical Workstations 1. In an air contrast-upper GI a. a small nasogastric tube is placed for air insufflation b, citrocarbonate is swallowed with a small amount of water c. the barium-sulfate suspension is unflavored d. contrast is swallowed first to allow sufficient gastric expansion 2. Regarding musculoskeletai radiography a. bones have a "shell" structure b. MR imaging is quickly becoming the exam of choice after acute trauma c. ultrasound of the tendons is now superseded by arthrography d. CT scanning is used to stage and characterize neoplasms 3. The midline anechoic structure on a neonatal head ultrasound represents the a, cerebellar vermis b. clivus c. lenticulostriate artery d. cavum septum pellucidum GI = gastrointestinal examination, MRI = magnetic resonance imaging, CT = computed tomography. RESULTS
FIGURE 2. Sample page from one clinical area showing five teaching points, resident's initials, and notes taken by student.
One hundred eight students participated in the study, which incorporated the first 18 rotations of the academic year. Fifty-four students carried a Radiology Passport and 54 did not. Results are shown in Table 3. The group carrying
TABLE 2: Questionnaire Given to Students on Completion of Course A. In addition to scheduled hours, how many preparation hours (reading, etc.) did you devote per week to the clerkship? B. How many hours per week did you spend in formal teaching sessions, i.e., lectures, small group discussions, etc.? C. Not counting preparation hours or formal teaching hours, how many hours per week did you work? Please rate the clerkship in the following areas:
1. 2. 3. 4. 5. 6. 7. 8.
Poor
Fair
Satisfactory
Good
Excellent
1
2
3
4
5
Overall knowledge gained Clinical skills gained Organization and structure Quality of lectures, conferences, seminars Adequacy of instructor feedback Interaction with residents Interaction with faculty and attending physicians Overall quality of the learning experience Not recommend 1
Recommend 2
3
4
5
9. Would you recommend this clerkship to students with similar interests? Too little 1 10. 11. 12. 13. 14.
Optimal 2
3
Too much 4
5
Patient volume Variety of caseload mix and pathology Reponsibility given to student Didactic and formal teaching Amount of curriculum time allocated for this clerkship I
Response rate was more than 90%. 347
Vol. 2, No. 4, April 1995
MERHAR
TABLE 3: Results of Comparison of Passport and Nonpassport Groups Passport
Nonpassport
p~
Variable Pretest Posttest Posttest gain Preparation hours Formal hours per week Nonpreparation, nonteaching hours per week Overall knowledge gained Clinical skills gained Organization and structure Exposure to clinical practice Quality of lectures and seminars Adequacy of instructor feedback Interaction with residents Interaction with faculty Quality of learning experience Recommend to others?
M
SD
M
SD
18.96 30.06 11.10 11.38 11.56 20.80 4.07 3.37 3.70 3.47 4.07 3.94 3.75 3.70 4.02 4.25
3.37 2.18 3.62 5.48 5.34 12.42 0.578 1.02 0.882 0.902 0.669 0.881 0.830 0.792 0.765 0.731
19.74 28.20 8.46 10.58 12.64 11.69 3.93 3.38 3.54 3.04 3.87 3.46 2.72 3.12 3.40 3.33
3.49 3.28 3.90 6.69 8.48 9.05 0.723 0.953 0.926 0.912 0.795 1.13 0.87 0.875 0.955 1.00
.258 .003 .001 .509 .440 .000 .242 .951 .340 .020 .156 .018 .000 .000 .000 .000
M = mean, SD = standard deviation. aSignificancewas set at the .05 level.
the passport had a 31% improvement in their scores when comparing the pre- and posttest (p < .001). The mean pretest score for the passport group was 18.96; the mean posttest score was 30.06. Students without passports scored a mean of 19.74 on the pretest and 28.20 on the posttest. The questionnaire comparison showed statistically significant differences between the passport and the nonpassport groups. Interaction with residents was higher in the passport group than in the nonpassport group (p < .0005). Interaction with faculty was higher (p < .0005), and adequacy of instructor feedback was more favorably rated (p < .018).
Exposure to clinical practice was higher in the passport group (p < .02). The hours per week spent in formal teaching sessions and preparation hours was similar, but the number of hours spent working in the department (total hours minus preparation and formal teaching hours) was significantly increased for the passport group (p < .0005). To evaluate trends in the test and the questionnaire results, the clerkship groups were divided into a first half (groups 1-9 comprising students 1-54) and a second half (groups 10-18 comprising students 55-108). A comparison of these groups (Table 4) s h o w e d a trend
TABLE 4: Scores of Passport Versus Nonpassport Groups 1-9 and Groups 10-18 Groups 10-18
Groups 1-9 Variable Pretest Posttest Posttest gain Preparation hours Formal hours per week Nonpreparation, nonteaching hours per week Overall knowledge gained Clinical skills gained Organization and structure Exposure to clinical practice Quality of lectures and seminars Adequacy of instructor feedback Interaction with residents Interaction with faculty Quality of learning experience Recommend to others? aSignificancewas set at the .05 revel 348
Passport
Nonpassport
pa
Passport
Nonpassport
pa
18.39 29.61 11.22 10.59 10.77 19.40 4.17 3.19 3.74 3.52 4.09 4.04 3.82 3.56 4.17 4.35
19.05 28.09 9.05 10.24 13.36 9.78 4.04 3.44 3.52 2.96 3.89 3.73 2.54 3.07 3.14 3.11
.455 .037 .050 .850 .239 .009 .438 .390 .394 .040 .292 .192 .000 .045 .000 .000
19.44 30.44 11.00 11.97 12.13 21.73 4.00 3.50 3.68 3.43 4.06 3.86 3.71 3.81 3.90 4.17
20.24 28.28 8.03 10.92 11.92 13.61 3.81 3.33 3.56 3.12 3.85 3.19 2.93 3.15 3.67 3.56
.440 .026 .007 .520 .905 .005 .307 .534 .617 .220 .326 .037 .001 .004 .308 .014
Vol. 2, No. 4, April 1995
MEDICAL
for higher evaluations of faculty interaction in the passport groups as the year progressed (groups 1-9, p < .045; groups 10-18, p < .004). Interactions with residents remained significantly better for the passport group (p < .0001) than for the nonpassport group (p < .001), although the nonpassport students noted increasing interaction as the academic year progressed. The overall quality of the learning experience was rated better in the first half with the passport students (p < .0001) than in the second half (p < .308). The overall hours spent in the department went up slightly in the second half (p < .009 versus p < .005), but the difference in significance between the passport and nonpassport groups were similar (p < .009 versus p < .005). Preand posttest results did not significantly change from the beginning of the trial to the end, as shown in Figure 3.
DISCUSSION
The need for quality radiology education for medical students has b e e n stated for decades [2-4]. However, faculty clinical workloads are increasing and many departments are experiencing decreasing subsidies for education. Many writings on radiology education have emphasized faculty-intensive lectures and film-reading sessions. Others stress the independence of the students and recommend small-group, peer-interactive teaching [5-7]. The structure of a course has b e e n shown to be important [8, 9]. Like departments offering nonradiology clerkships that rely on clinical interaction for most of their teaching, radiology departments can easily place students throughout
STUDENT
INTERACTION
their clinical areas for a good part of the day. Nonetheless, clinical interaction at the alternator or view box is often difficult. The medical student who asks many questions is labeled aggressive, irritating, and obnoxious. The student who quietly observes is labeled passive and shy. Medical students have a difficult time judging what behaviors are just right to enhance their learning. The Radiology Passport standardizes the clinical interaction of the students by making them ask questions at the clinical stations. As shown by the questionnaire, the passport group reported significantly higher interaction with the residents. Attendance during the day within the department was dramatically increased, with the passport students spending nearly twice as many hours as the nonpassport group. Although we do not advocate placing the teaching load on our residents, we feel they are a valuable resource for education and can be effectively used without compromising their own clinical time. The passport students learned more clinical points than the nonpassport group during their clerkships as shown by the improvement on their posttest scores. The multiple-choice questions were designed to be unambiguous and to deal directly with the teaching points made at the workstations [10]. These practical teaching points were not knowingly included in either the morning teaching sessions or the didactic lectures. The use of identical pre- and posttests has been criticized [11] because the examinees might retain some of the pretest questions. By giving the pretest the first day as the students entered the department and by allowing only 30 seconds per answer on the pre- and posttests, we felt the memorization factor would be minimized. There
35
3O
25
FIGURE 3. Pre- and posttest results from beginning to end of trial. Passport and nonpassport groups are combined.
'i
19 Jul
2 Aug
16 Aug
30 Aug
13 Sep
27 Sep
11 Oct
25 Oct
8 Nov
22 Nov
6 Dec
4 Jan
31 Jan
14 Feb
349
MERHAR
appeared to be little crossover of test information to future groups, as there was no real trend toward improved pre- and posttest scores as the academic year progressed (Fig. 3). It also appeared that the clinical radiology information taught at the clinical stations was unique to radiology, as the medical students did not gain this information during earlier nonradiology clerkships. The perception of increased interaction with the faculty was a surprising but welcome finding. As our faculty devote 100% of their scheduled time to clinical practice, it is no w o n d e r that the students with the passports would have the ability to interact with them. But the perceived improvement of the interaction from the first to the second half of the trial suggests that the faculty are becoming more involved with the medical students at the subspecialty stations. Throughout the trial, the students with passports felt that the instructor feedback was higher; the increased clinical interaction may have had a positive effect with the faculty on other aspects of the course, such as the morning sessions and the didactic lectures. The fact that the gap between the passport groups' and the nonpassport groups' perceived overall quality of the learning experience for the clerkship decreased between the first and second halves of the trial might have two explanations. As the interaction of the faculty and residents with the medical students increased, the interaction may have spread across the groups whether or not they carried a passport. This would be a welcome improvement in the students' education. Another explanation might be that the novelty of this new technique had worn off as the academic year progressed. However, several key areas, notably the posttest gain differential, actually went up in the second half (groups 1-9, p < .05; groups 10-18, p < .007). The effect of the passport on clinical knowledge gain did not diminish with time. The questions on the course evaluations used a grading scale of 1 (fit) to 5 (best). This scale was chosen by the dean's office to facilitate entry into a scan-sheet service provided by the University of Cincinnati. The two questions most scrutinized by our institution in course evaluation by students concern rating the overall quality of the learning experience in the clerkship and whether
350
Vol. 2, No. 4, April 1995
the student would recommend the clerkship to students with similar interests. Both questions had a significantly higher score from the passport group than from the nonpassport group. The variance on individual questions was moderately large, in part because one student's "5" might only be another student's "3." However, we were able to demonstrate statistically significant differences in several categories. In addition, although the increased posttest gains by the passport group might seem small, they were significantly improved. We feel that the inexpensive assembly and the portability of these passports, the wide range of course improvements, the quantitative increases in scores and in student perceptions of the clerkship make the passport a prudent investment by a department and a course director.
ACKNOWLEDGMENTS
I thank Joe Stoner, MS, of the Education Division of the Office of the Dean, University of Cincinnati College of Medicine, for his help with statistical analysis; and John Quinlan, MD, Director of Education, Department of Neurology, University of Cincinnati College of Medicine, for his encouragement of faculty educators to try the passport concept in their courses.
REFERENCES 1. Squire LF, Novelline RA. Fundamentals of radiology. Cambridge, MA: Harvard University Press, 1988. 2. Bloomfield JA. Radiology: focus of the medical curriculum? A JR 1982; 138:980-981. 3. Love MB. Teaching radiology to medical students. AJR 1980;134:1089-1090. 4. Squire LF, Novelline RA. Radiology should be a required part of the medical school curriculum. Radiology 1985; 156:243-244. 5. Squire LF. On teaching radiology to medical students: challenges for the nineties. A JR 1989;152:457--461. 6. Messmer JM, Papp KK, Hurwitz J, Cook DE. Development of an effective short introductory course in diagnostic radiology. Invest Radio11989;24:631-633. 7. Chen MYM, Ott DJ, Richards B. Impact and value of junior rotation in radiology. Invest Radio11990; 25:1153-1155. 8. Sider L, Rogers LF. The value of a structured course for an elective in radiology for senior medical students. Invest Radio11989;24:412-415. 9. Blane CE, Calhoun JG, Maxim BR, Martel W, Davis WK. Systematic evaluation and increased structure in a radiology elective. Invest Radiol 1985;20:242-245. 10. Vydareny KH, Blane CE, Calhoun JG. Guidelines for writing multiplechoice questions in radiology courses. Invest Radio11986;21:871-876. 11. Blane CE, Calhoun JG, Vydareny KH. Constructing pre- and post-tests in a medical student elective. Invest Radio11986;21:743-745.
Increasing Medical Student Interaction: The Radiology Passport Gary L. Merhar, MD
Rationale and Objectives. A pocket-sized booklet and learning aid, the "Radiology Passport," was introduced into the radiology clerkship. A study was devised to assess the effectiveness of the Radiology Passport on the clinical interaction of junior medical students during their required 2-week clerkship. Methods. The Radiology Passport contained the student's identification picture and a list of teaching points to be learned in each subspecialty station area. The Radiology Passport was given to alternating groups of junior medical students to be carried during their 2week clerkship. All students were given a pre- and posttest with questions relating specifically to the clinical stations. In addition, results of a standardized course evaluation designed by the dean's office of the medical school were analyzed. The groups with and without Radiology Passports were then compared. Results. The groups carrying the Radiology Passports had significant improvement on their posttest scores compared with the nonpassport group. In addition, there was a significant increase in the perceived interaction with residents and faculty, instructor feedback, the overall quality of learning, and the amount of time the students actually spent in the department over the 2 weeks. Conclusion. The Radiology Passport is an easy, inexpensive learning aid that improves the quality of education and clinical interaction during the radiology clerkship. Key Words. Education; medical students; radiology learning; teaching model.
he radiology clerkship at the University of Cincin-
T nati College of Medicine is a required course in the
junior year. The radiology clerkship is 2 weeks in length with four to eight students per session. The University Hospital is the only teaching site for the junior radiology clerkship. A senior clerkship is 4 weeks in length and is run separately. The daily schedule for the junior clerkship includes a plain film interpretation session with faculty, clinical interaction at workstations throughout the department, a small peer-group film interpretation session, a lunchtime departmentwide conference, and a clinical problem-solving lecture given by faculty. Fundamentals of Radiology by Lucy Frank Squire and Robert Novelline is the required text [1]. For years the weakest part of the clerkship has been the clinical interaction of the students in the department. The students have complained about the poor teaching by residents and the inability to learn radiology in the clinical setting. The lack of interest shown to students has caused daily attendance to suffer. Keeping track of clinical attendance has proven to be logistically impossible. Because our department feels strongly that this clinical time is important to the students' radiology education, a simple teaching tool, the Radiology Passport, was developed. Each page of the passport contains five teaching points for each of nine clinical areas. These teaching points have been submitted by the department section heads. The students are at the clinical stations for 3 hr per
From the Department of Radiology, University Hospital, Cincinnati, OH.
Address reprint requests to G. L. Merhar, MD, Department of Radiology, University Hospital, 234 Goodman St., Cincinnati, OH 45267-0742. Received February 16, 1994, and accepted for publication after revision November 22, 1994. Acad Radio11995;2:345-350 © 1995, Association of University Radiologists
345
MERHAR
day and rotate to a new station daily. At the end of their scheduled clinical time, a resident, fellow, or staff assigned to the clinical station signs the medical student's passport, indicating that the student learned the five teaching points. The students turn in their passports to the course director at the end of their clerkship. To test the hypothesis that the passport improved clinical interaction and learning, only alternating 2w e e k groups were given the passport. The nonpassport group otherwise had an identical experience. Both groups were given identical pre- and posttests designed to test their observations at the clinical stations. At the end of the course, a standard questionnaire was filled out by the students. This questionnaire was designed by the dean's office to help in assessing all clerkships. We c o m p a r e d the results of the pre- and posttests and questionnaires of the passport and nonpassport groups.
Vol. 2, No. 4, April 1995
A
MATERIALS AND METHODS Mtemating groups of third-year medical students were given Radiology Passports. The passport is a pocket-sized booklet designed to look like a U.S. passport and contains the student's identification photograph and signature (Fig. 1). It contains a list of teaching points divided by clinical sections and a space for the resident or faculty to sign (Fig. 2). The students carried these passports to the nine clinical stations, which were abdominal imaging, gastrointestinal fluoroscopy, neuroradiology, pediatric radiology (at the Cincinnati Childrens' Hospital), nuclear medicine, emergency radiology, chest radiology, sonography, and orthopedic radiology. Groups without passports were given the same clinical assignments. A list of the teaching points was available at each clinical area so that the nonpassport group might have the same opportunity to learn. A multiple-choice test with 40 questions related to the teaching points was given to all students immediately after they assembled in the radiology department on the first day. The identical test was given on the final day of the clerkship. Sample questions are listed in Table 1. A standard questionnaire was filled out by both groups at the time of the final written examination on the last day of the course. The questionnaire asked the students to grade various attributes of the clerkship on a scale of 1 to 5. Table 2 illustrates a sample questionnaire.
Analysis The test scores and questionnaire results were entered into a database, and statistical analysis of the results of the two groups was performed using Statistical Package for the Social Sciences (SPSS) for Windows, Volume 6 346
B FIGURE 1. A and B, The "Radiology Passport" cover (A) and student ID photograph and signature (B).
(SPSS, Chicago, IL). The differences in pre- and posttest results were compared using the paired t test. Course evaluation questions were compared using t tests for independent samples. Levene's test for equality of variances was used to choose between p values to ensure comparable variances between samples. Because not all questions On the evaluation were answered by all the students, the n values for some variables differed.
Vol. 2, No. 4, April 1995
MEDICAL STUDENT INTERACTION TABLE 1: Sample Pre- and Posttest Questions Based on Points Learned at Clinical Workstations 1. In an air contrast-upper GI a. a small nasogastric tube is placed for air insufflation b, citrocarbonate is swallowed with a small amount of water c. the barium-sulfate suspension is unflavored d. contrast is swallowed first to allow sufficient gastric expansion 2. Regarding musculoskeletai radiography a. bones have a "shell" structure b. MR imaging is quickly becoming the exam of choice after acute trauma c. ultrasound of the tendons is now superseded by arthrography d. CT scanning is used to stage and characterize neoplasms 3. The midline anechoic structure on a neonatal head ultrasound represents the a, cerebellar vermis b. clivus c. lenticulostriate artery d. cavum septum pellucidum GI = gastrointestinal examination, MRI = magnetic resonance imaging, CT = computed tomography. RESULTS
FIGURE 2. Sample page from one clinical area showing five teaching points, resident's initials, and notes taken by student.
One hundred eight students participated in the study, which incorporated the first 18 rotations of the academic year. Fifty-four students carried a Radiology Passport and 54 did not. Results are shown in Table 3. The group carrying
TABLE 2: Questionnaire Given to Students on Completion of Course A. In addition to scheduled hours, how many preparation hours (reading, etc.) did you devote per week to the clerkship? B. How many hours per week did you spend in formal teaching sessions, i.e., lectures, small group discussions, etc.? C. Not counting preparation hours or formal teaching hours, how many hours per week did you work? Please rate the clerkship in the following areas:
1. 2. 3. 4. 5. 6. 7. 8.
Poor
Fair
Satisfactory
Good
Excellent
1
2
3
4
5
Overall knowledge gained Clinical skills gained Organization and structure Quality of lectures, conferences, seminars Adequacy of instructor feedback Interaction with residents Interaction with faculty and attending physicians Overall quality of the learning experience Not recommend 1
Recommend 2
3
4
5
9. Would you recommend this clerkship to students with similar interests? Too little 1 10. 11. 12. 13. 14.
Optimal 2
3
Too much 4
5
Patient volume Variety of caseload mix and pathology Reponsibility given to student Didactic and formal teaching Amount of curriculum time allocated for this clerkship I
Response rate was more than 90%. 347
Vol. 2, No. 4, April 1995
MERHAR
TABLE 3: Results of Comparison of Passport and Nonpassport Groups Passport
Nonpassport
p~
Variable Pretest Posttest Posttest gain Preparation hours Formal hours per week Nonpreparation, nonteaching hours per week Overall knowledge gained Clinical skills gained Organization and structure Exposure to clinical practice Quality of lectures and seminars Adequacy of instructor feedback Interaction with residents Interaction with faculty Quality of learning experience Recommend to others?
M
SD
M
SD
18.96 30.06 11.10 11.38 11.56 20.80 4.07 3.37 3.70 3.47 4.07 3.94 3.75 3.70 4.02 4.25
3.37 2.18 3.62 5.48 5.34 12.42 0.578 1.02 0.882 0.902 0.669 0.881 0.830 0.792 0.765 0.731
19.74 28.20 8.46 10.58 12.64 11.69 3.93 3.38 3.54 3.04 3.87 3.46 2.72 3.12 3.40 3.33
3.49 3.28 3.90 6.69 8.48 9.05 0.723 0.953 0.926 0.912 0.795 1.13 0.87 0.875 0.955 1.00
.258 .003 .001 .509 .440 .000 .242 .951 .340 .020 .156 .018 .000 .000 .000 .000
M = mean, SD = standard deviation. aSignificancewas set at the .05 level.
the passport had a 31% improvement in their scores when comparing the pre- and posttest (p < .001). The mean pretest score for the passport group was 18.96; the mean posttest score was 30.06. Students without passports scored a mean of 19.74 on the pretest and 28.20 on the posttest. The questionnaire comparison showed statistically significant differences between the passport and the nonpassport groups. Interaction with residents was higher in the passport group than in the nonpassport group (p < .0005). Interaction with faculty was higher (p < .0005), and adequacy of instructor feedback was more favorably rated (p < .018).
Exposure to clinical practice was higher in the passport group (p < .02). The hours per week spent in formal teaching sessions and preparation hours was similar, but the number of hours spent working in the department (total hours minus preparation and formal teaching hours) was significantly increased for the passport group (p < .0005). To evaluate trends in the test and the questionnaire results, the clerkship groups were divided into a first half (groups 1-9 comprising students 1-54) and a second half (groups 10-18 comprising students 55-108). A comparison of these groups (Table 4) s h o w e d a trend
TABLE 4: Scores of Passport Versus Nonpassport Groups 1-9 and Groups 10-18 Groups 10-18
Groups 1-9 Variable Pretest Posttest Posttest gain Preparation hours Formal hours per week Nonpreparation, nonteaching hours per week Overall knowledge gained Clinical skills gained Organization and structure Exposure to clinical practice Quality of lectures and seminars Adequacy of instructor feedback Interaction with residents Interaction with faculty Quality of learning experience Recommend to others? aSignificancewas set at the .05 revel 348
Passport
Nonpassport
pa
Passport
Nonpassport
pa
18.39 29.61 11.22 10.59 10.77 19.40 4.17 3.19 3.74 3.52 4.09 4.04 3.82 3.56 4.17 4.35
19.05 28.09 9.05 10.24 13.36 9.78 4.04 3.44 3.52 2.96 3.89 3.73 2.54 3.07 3.14 3.11
.455 .037 .050 .850 .239 .009 .438 .390 .394 .040 .292 .192 .000 .045 .000 .000
19.44 30.44 11.00 11.97 12.13 21.73 4.00 3.50 3.68 3.43 4.06 3.86 3.71 3.81 3.90 4.17
20.24 28.28 8.03 10.92 11.92 13.61 3.81 3.33 3.56 3.12 3.85 3.19 2.93 3.15 3.67 3.56
.440 .026 .007 .520 .905 .005 .307 .534 .617 .220 .326 .037 .001 .004 .308 .014
Vol. 2, No. 4, April 1995
MEDICAL
for higher evaluations of faculty interaction in the passport groups as the year progressed (groups 1-9, p < .045; groups 10-18, p < .004). Interactions with residents remained significantly better for the passport group (p < .0001) than for the nonpassport group (p < .001), although the nonpassport students noted increasing interaction as the academic year progressed. The overall quality of the learning experience was rated better in the first half with the passport students (p < .0001) than in the second half (p < .308). The overall hours spent in the department went up slightly in the second half (p < .009 versus p < .005), but the difference in significance between the passport and nonpassport groups were similar (p < .009 versus p < .005). Preand posttest results did not significantly change from the beginning of the trial to the end, as shown in Figure 3.
DISCUSSION
The need for quality radiology education for medical students has b e e n stated for decades [2-4]. However, faculty clinical workloads are increasing and many departments are experiencing decreasing subsidies for education. Many writings on radiology education have emphasized faculty-intensive lectures and film-reading sessions. Others stress the independence of the students and recommend small-group, peer-interactive teaching [5-7]. The structure of a course has b e e n shown to be important [8, 9]. Like departments offering nonradiology clerkships that rely on clinical interaction for most of their teaching, radiology departments can easily place students throughout
STUDENT
INTERACTION
their clinical areas for a good part of the day. Nonetheless, clinical interaction at the alternator or view box is often difficult. The medical student who asks many questions is labeled aggressive, irritating, and obnoxious. The student who quietly observes is labeled passive and shy. Medical students have a difficult time judging what behaviors are just right to enhance their learning. The Radiology Passport standardizes the clinical interaction of the students by making them ask questions at the clinical stations. As shown by the questionnaire, the passport group reported significantly higher interaction with the residents. Attendance during the day within the department was dramatically increased, with the passport students spending nearly twice as many hours as the nonpassport group. Although we do not advocate placing the teaching load on our residents, we feel they are a valuable resource for education and can be effectively used without compromising their own clinical time. The passport students learned more clinical points than the nonpassport group during their clerkships as shown by the improvement on their posttest scores. The multiple-choice questions were designed to be unambiguous and to deal directly with the teaching points made at the workstations [10]. These practical teaching points were not knowingly included in either the morning teaching sessions or the didactic lectures. The use of identical pre- and posttests has been criticized [11] because the examinees might retain some of the pretest questions. By giving the pretest the first day as the students entered the department and by allowing only 30 seconds per answer on the pre- and posttests, we felt the memorization factor would be minimized. There
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FIGURE 3. Pre- and posttest results from beginning to end of trial. Passport and nonpassport groups are combined.
'i
19 Jul
2 Aug
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30 Aug
13 Sep
27 Sep
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25 Oct
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MERHAR
appeared to be little crossover of test information to future groups, as there was no real trend toward improved pre- and posttest scores as the academic year progressed (Fig. 3). It also appeared that the clinical radiology information taught at the clinical stations was unique to radiology, as the medical students did not gain this information during earlier nonradiology clerkships. The perception of increased interaction with the faculty was a surprising but welcome finding. As our faculty devote 100% of their scheduled time to clinical practice, it is no w o n d e r that the students with the passports would have the ability to interact with them. But the perceived improvement of the interaction from the first to the second half of the trial suggests that the faculty are becoming more involved with the medical students at the subspecialty stations. Throughout the trial, the students with passports felt that the instructor feedback was higher; the increased clinical interaction may have had a positive effect with the faculty on other aspects of the course, such as the morning sessions and the didactic lectures. The fact that the gap between the passport groups' and the nonpassport groups' perceived overall quality of the learning experience for the clerkship decreased between the first and second halves of the trial might have two explanations. As the interaction of the faculty and residents with the medical students increased, the interaction may have spread across the groups whether or not they carried a passport. This would be a welcome improvement in the students' education. Another explanation might be that the novelty of this new technique had worn off as the academic year progressed. However, several key areas, notably the posttest gain differential, actually went up in the second half (groups 1-9, p < .05; groups 10-18, p < .007). The effect of the passport on clinical knowledge gain did not diminish with time. The questions on the course evaluations used a grading scale of 1 (fit) to 5 (best). This scale was chosen by the dean's office to facilitate entry into a scan-sheet service provided by the University of Cincinnati. The two questions most scrutinized by our institution in course evaluation by students concern rating the overall quality of the learning experience in the clerkship and whether
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the student would recommend the clerkship to students with similar interests. Both questions had a significantly higher score from the passport group than from the nonpassport group. The variance on individual questions was moderately large, in part because one student's "5" might only be another student's "3." However, we were able to demonstrate statistically significant differences in several categories. In addition, although the increased posttest gains by the passport group might seem small, they were significantly improved. We feel that the inexpensive assembly and the portability of these passports, the wide range of course improvements, the quantitative increases in scores and in student perceptions of the clerkship make the passport a prudent investment by a department and a course director.
ACKNOWLEDGMENTS
I thank Joe Stoner, MS, of the Education Division of the Office of the Dean, University of Cincinnati College of Medicine, for his help with statistical analysis; and John Quinlan, MD, Director of Education, Department of Neurology, University of Cincinnati College of Medicine, for his encouragement of faculty educators to try the passport concept in their courses.
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