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

Abstract

Background: The Choosing Wisely campaign highlights the importance of clinical reasoning abilities for competent and reflective physicians. The principles of this campaign should be addressed in undergraduate medical education. Recent research suggests that answering questions on important steps in patient management promotes knowledge retention. It is less clear whether increasing the authenticity of educational material by the inclusion of videos further enhances learning outcome.

Methods: In a prospective randomised controlled cross-over study, we assessed whether repeated video-based testing is more effective than repeated text-based testing in training students to choose appropriate diagnostic tests, arrive at correct diagnoses and identify advisable therapies. Following an entry exam, fourth-year undergraduate medical students attended 10 weekly computer-based seminars during which they studied patient case histories. Each case contained five key feature questions (items) on the diagnosis and treatment of the presented patient. Students were randomly allocated to read text cases (control condition) or watch videos (intervention), and assignment to either text or video was switched between groups every week. Using a within-subjects design, student performance on video-based and text-based items was assessed 13 weeks (exit exam) and 9 months (retention test) after the first day of term. The primary outcome was the within-subject difference in performance on video-based and text-based items in the exit exam.

Results: Of 125 eligible students, 93 provided data for all three exams (response rate 74.4%). Percent scores were significantly higher for video-based than for text-based items in the exit exam (76.2 ± 19.4% vs. 72.4 ± 19.1%, p = 0.026) but not the retention test (69.2 ± 20.2% vs. 66.4 ± 20.3%, p = 0.108). An additional Bayesian analysis of this retention test suggested that video-based training is marginally more effective than text-based training in the long term (Bayes factor 2.36). Regardless of presentation format, student responses revealed a high prevalence of erroneous beliefs that, if applied to the clinical context, could place patients at risk.

Conclusion: Repeated video-based key feature testing produces superior short-term learning outcome compared to text-based testing. Given the high prevalence of misconceptions, efforts to improve clinical reasoning training in medical education are warranted. The Choosing Wisely campaign lends itself to being part of this process.

Keywords: Choosing wisely; Clinical reasoning; Medical education; Test-enhanced learning; Video.

Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the local Ethics Committee (application number 22/4/15), and all participants provided written consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Figures

Fig. 1

Flow of participants through the study. Orange boxes, video cases; blue boxes, text cases. Contamination occurred when students were erroneously exposed to the wrong presentation format (by reporting to the computer room assigned to the other group) at least once

Fig. 2

Trajectories of student performance in video-based and text-based items, respectively. The first presentation (‘1st occurrence’) of a particular item in an e-seminar occurred between week 3 and week 9; the second item presentation occurred between week 5 and week 11 (‘2nd occurrence’). In order to increase legibility, data collected during first and second occurrences, respectively, were collapsed into two data collection points although data were actually collected over a period of 6 weeks for each occurrence