Quality learning in undergraduate medical education - Improving teaching and assessment practices

Abstract

Although there have been significant advancements in our understanding of human learning over the last century, many educational practices within the medical field have not integrated educational research findings. Conventional classroom teaching still heavily depends on lecture-based techniques, while clinical teaching frequently lacks sufficient opportunities for assessment and feedback on clinical skills. Moreover, a considerable portion of assessment content falls short in accurately reflecting important and authentic clinical challenges that newly graduated doctors are likely to encounter in their daily practice. This compromises the validity of the assessments and its ability to fully capitalise on its potential impact on student learning.

The aim of this thesis was to develop and implement changes to classroom teaching, clinical teaching and assessment practices in the medical curriculum at the Norwegian University of Science and Technology (NTNU). The research was underpinned by constructivist learning theories and focused on evaluating effects on educational impact and assessment quality.

Paper I examines the implementation of a modified, time-efficient Team-based learning (TBL) approach called express TBL. It fostered high levels of engagement and students reported significantly higher satisfaction and learning when compared to traditional lectures. However, in a cross-over design with 105 third-year students, it showed no improvement in performance on a summative examination compared to traditional lectures.

Paper II examines the implementation of formative mini-Clinical Evaluation Exercise (mini-CEX) assessments during a clinical placement for 38 fifth-year students. Students were generally positive to their use, but in a randomised controlled trial (RCT) design, showed no overall improvement on direct observation, feedback or performance compared with ad-hoc feedback. However, feedback on history taking skills were reported significantly more common in the intervention (mini-CEX) group.

Paper III examines a novel quality assurance procedure for in-house examinations: external double-blinded review of assessment items by clinicians. In all, 1353 items were reviewed by 170 external reviewers, of which 20% were either rejected or judged as needing revision. Content relevance, content accuracy and technical flaws emerged as the main reasons for not approving items. Following review and feedback, changes were made to 40% of disapproved items, which constitutes almost 10% of the totalnumber of items that were reviewed. This study showed that external peer review is cost-effective and feasible in an in-house setting with fewer resources available, and can identify items that have the potential to significantly reduce the validity and educational impact of examinations. Grounded in learning theory, these projects were designed with the aim of enhancing the quality of learning within the medical curriculum. Throughout this thesis, a central focus has been placed on feasibility to ensure that the proposed changes are viable within a realistic educational setting. Although the search for evidence demonstrating educational impact in terms of improved student outcomes presented challenges, it sparked numerous inquiries for future exploration.