REBUILDING
EDUCATION

Analysis

Experience

As medical students ourselves, we know firsthand that we have lots of stuff to learn. Currently we have an exam every four weeks, in which we answer multiple choice or open questions about the information given in lectures, discussion groups, practicals and books. However, most of the time this results in students doing not so much for the first three weeks and then they try to study as much as possible in the remaining week before the exam. This creates a stressful way of studying, as there is so much to revise. It also reduces the amount of information students will remember on a long term. Students often sleep bad, try to study till late at night with coffee and energy drinks and panic when they realise they should have started earlier if they wanted to read everything they need to. In the end, they will probably pass their test, but when you ask them anything of the study materials six months later, it is highly unlikely that they are still able to remember it. This means the course could be seen as not sufficient and ineffective to gain enough knowledge in anatomy. The educational designers of VU medical school do realise this, as they created a second year course in which anatomical structures (that were part of a first year course) are assessed all over again. However, if students again fail to study continuously and keep up with (anatomical) lectures, it is doubtful whether they did gain enough knowledge this time.

In our redesign we will take a first year course as an example, called Anatomy & Movement. Our redesign could be useful in all bachelor courses as they all have a ‘learning facts and data’ part and more contextual, conceptual knowledge part. In Anatomy & Movement the ‘learning facts and data’ part consists of anatomical structures, whereas the other part consists of histology, physiology, pathophysiology and physical examination skills, so that part is more ‘understanding’ knowledge. It is the second course of the year and takes place in October. When taking this course as a student, you are relatively new in Medicine and it is important to keep up with the schedule. The introduction of this course is overwhelming, especially the first anatomy lectures. There are a lot of book chapters that you are required to study, about as much as the course before, but now there is also an item list with anatomical structures. This list consists of bones, muscles, nerves, arteries and veins through the entire body. Even if you had a good grade for Latin in high school, it is hard to keep up with the lecturer in the beginning. When the anatomical structures are revised, during the practical in the dissecting room, most students haven’t learned all the structures yet. As a result, this practical sessions become quite inefficient and ineffective.

The junior teachers have to explain exactly what the lecturer already pointed out, where instead they could have been helping all groups a bit with the difficulties in X-rays. Then there are also students that don’t even try to answer the questions during the practical session, they just sit and wait until they can go home again. In the end, the junior teachers and other staff do a lot of work for almost zero knowledge gained by the students, and the students have barely learnt what they need to during the practicals.

The same happens at the weekly brainstorm sessions that students are obligated to go to. The idea is that you discuss the subject matter that is presented earlier that morning at the lectures by brainstorming on questions with your study group. On Friday, there is another session in which the topics of the brainstorm are presented in smaller groups. In reality, only half of the students in the studygroup actually went to the lectures and there are only a few people who are really capable to brainstorm about the subject. This results in inefficient and ineffective brainstorm sessions where the dialogues are like this: “What are the most common causes of cerebral palsy?” “There was a lecture on it this morning, but I don’t remember. The internet says this.” “Okay, maybe the students that present this topic on Friday can look into that a bit more.” Most study groups are done within half of the time they get for the brainstorm, students walking out with low energy levels and little new knowledge.

Participation

To re-experience the anatomic lectures of year one, we visited one during the third week of the Anatomy and Movement course. Again, it was clear that most students were not able to keep up with the lecturer, use of laptops for facebook and email increased during the lecture. A lot of students were discussing they should have learned the anatomy earlier, more in the beginning of the course. Although the introduction lecture already stresses how important a good start is in this course, reality shows most students are not able to achieve this by themselves. We think it might be better to push them a bit harder, so they start earlier and learn more in longer term. We asked a few fellow students how they would feel about this and although they were not really happy with the idea of more assessments they understood why it might be better on the long run. Also, they agreed that it would probably cause less stress and create higher levels of effectivity in learning.

When asked what else they thought of as inefficient or ineffective in the medical bachelor’s program, they came up with the study groups that were mentioned above. The brainstorm sessions are mainly advanced google search sessions and the presentations sometimes lack quality as well. Students copy the powerpoints from other groups and are unable to answer questions from the group. The quality of the presentation is usually higher when students receive feedback from the tutor on a regular basis. Also, the brainstorm sessions are perceived as better in groups when the tutor has a medical background compared to those where the tutor is from a completely different field.

Survey

To gain information on a larger scale, we did a survey with medical bachelor students. Our goal was to obtain information about how well students are able to remember all the facts they learned during the bachelor and to get a better view of the students’ perspective of our ideas for the redesign. Students needed to fill in their current bachelor year, so that we would be able to obtain separate results for all three bachelor years.

The first part of the survey consisted of 10 questions about the anatomy. We chose this specific subject, because this is implemented in the course anatomy and movement, which is the course we took as example for the rest of the bachelor courses. And because it is a first year course in the beginning of the year, we were able to include the first years in our survey as well.

The questions of the anatomy part of the survey were comparable to questions that were asked on final exams in previous years. This means that they consisted of either naming the right structures, naming the right innervation or vascularization, naming the right function or linking a disease pattern to the anatomical structures that are affected in the disease. Furthermore, we made sure to include question that varied in their level of difficulty and to include some questions that were twice a year repeated during a “ready knowledge” pass or fail test. In this way we would be able to analyze the effect of repetition on learning of facts and distinguish between students that might remember some points but forgot most and students that actually remember all essential parts and thus probably started studying earlier in the course.

The second part of the survey aimed to evaluate whether or not and at which moments during the bachelor courses students experience stress. Again we took the course “anatomy and movement” as an example.

The last part of the survey consisted of questions that aimed to evaluate our ideas for the redesign amongst the students. We made a prediction of the results of the analysis about knowledge of facts and the analysis of experienced stress levels, and based on this we made suggestions for a redesign. We formulated these suggestions as questions that could be answered by the students.They were able to answer these questions with either yes, no or maybe, and they were able to explain their answers if they liked to (this was not obligatory).

Predictions

We expected to see that first year students would score the best on the anatomy test, followed by the third year students and then the second year students. At the release moment of our survey, the first year students just finished the course “anatomy and movement”, so we think they should be able to answer most questions correctly.

In addition, during the second year, the anatomy of this course is repeated in another course, so we think third years should remember more about the anatomy than the second year students as third year students repeated the learning material once already.

Furthermore, based on our own experience and what we heard from our peers, we expect that most students will declare that they predominantly experience stress near the end of the course.

Lastly, our ideas for the redesign were extra test moments of the facts and data part of the courses (so in this case the anatomy) and an extra assignment, such as a presentation, that is marked and will be part of the final mark of the courses. However, we think that these ideas will mostly received negatively, because we think the students don’t like the idea of extra work. Moreover, what several peer students told us that they actually enjoy the free time of the first three weeks and think they need those high stress levels to perform well on exams and thus to  pass them.

Results

In total we had 160 responses; 76 first year students, 35 second year students, 43 third year students and 6 master students. We excluded the master students from our analysis so their were only 154 responses left.

The first part of our analysis consisted of making a distinction between the results of the first, second and third year students. To do this we added up all the right answers per year and then calculated the average mark. The first year students were able to answer 486 out of 760 questions correctly and thereby scored a 6.4. The second year students answered 144 out of 350 questions correctly and thus scored a 4.1. And lastly, the third year students answered 241 out of 430 questions correctly and therefore scored a 5.6.

In the second part of our analysis we investigated how different types of questions were made. Beforehand we picked three questions that we thought represented the types we wanted to investigate very well. These types were; a question that is repeated twice a year (figure 1), a question that can be correctly answer with basic knowledge of the anatomy and thinking logically (figure 2) and a question that cannot be answered by thinking logically, but the students must really know the answer (figure 3).

This provided the following results:

The figures show that 90.6% of the students were able to correctly answer the question that is repeated twice a year, that 61.3% of the students were able to correctly answer the “logical question” and that only 16.2% of the students were able to correctly answer the “know question”.

The third part of our analysis only compromised one question and was aimed to analyse the amount of stress students experienced and at which moments during our example course “anatomy and movement. Figure 4 represents the results and shows that 48.1% experienced stress predominantly during the last week of the course, that 25% experienced stress from the beginning of the course and that 26.9% experienced no stress.

In the last part of our analysis we investigated how well our ideas for the redesign were received under the bachelor students. We asked them if they thought the way bachelor courses are tested is effective and if they wanted, they got the opportunity to explain their answer. Figure 5 represents the results and shows that 63.4% thinks it actually is effective and that 36.9% thinks it is not effective. Students that were positive about the current testing situation mainly explained that they think it would simply be too much work if there would be open questions instead of multiple-choice. Students that did not like the current situation noted that now you can pass exams by guessing and thinking logically without really knowing and understanding the material

Next, we asked the students how they would find it when the stamp part of a course (in this case the anatomy) was tested on multiple moments during the course instead of only one time during the final exam. Figure 6 represents the results and shows that 38.8% answered yes, 30% maybe and 31.2% no.

Finally, we asked the students if they would prefer a situation where the final mark of a course is determined by both a final exam and an extra assignment such as a presentation above one final exam. Figure 7 represents the results and shows that 26.3% answered yes, 18.8% answered maybe and 55% answered no.

Interpretation

Our prediction mostly correspond well with the results. As we expected, first year students scored the best on the anatomy test, followed by the third year students and second year students respectively. From this we conclude that most information is only stored in the short term memory and not processed to remain in the long term memory. Furthermore, because third year students scored better than second year students, we conclude that repetition is very for information to be stored in the long term memory. In addition, as we predicted, most students only experience stress near the end of the course, but a significant part also already experiences stress from the beginning of courses.

However, our predictions about the evaluation of our redesign amongst students did not completely match the results. The results showed a significant part would prefer extra test moments of the facts and data part during the course and another big part might prefer it. Together they form the majority of the whole student population of our survey. Moreover, we expected that most students won’t  like the idea of an extra moment of assessment that could lower their final mark (especially because of the Cohen censorship that jacks up students results significantly), and although this is shown in the results, the majority is not overwhelming. To be able to further explain the resistance of an extra marked assessment in the form of a presentation we randomly asked some students from each bachelor year to their opinion. This resulted in three main reasons, the first one being that some teachers are more strict than others, which makes grading unfair. The second reason was that the presentations as they are right now often feel unnecessary, and another presentation that even gets marked will only increase the working load without it being useful. The third important reason was mostly presented by students who in the situation as it is right know achieve very high results (averages above a 9), because of the Cohen censorship. They did not like the idea of their mark being lowered, because of a presentation, for which according to them it is practically impossible to get a mark above a 9. However, not every student thought negatively about the thought of a final mark divided over a presentation and a final exam. They would prefer this situation and thought it would indeed be effective in reducing stress levels. In addition, they thought it could potentially improve their overall result, since for some students are better in presentations than making a multiple choice exam.

All together, this means that for our redesign we will try to implement extra test moments for the facts and data part of the courses and add an extra assessment moment in the form of a presentation, which will potentially lead to reduced stress levels and better storage of information in the long term memory.

Redesign

Table 1 shows the structure of medical bachelor courses in the current situation. The first three weeks are all the same with lectures and a brainstorm session on monday, one or more practicals on tuesday, lectures on wednesday, some more practicals on thursday and ending the week with a presentation and lectures. In the last week there are some final lectures and practicals and it ends with the final exam that completely determines the final mark of the course. This final exam consists roughly of 50% facts and data (anatomy in our example) and 50% clinical thinking and other subjects.

Based on the results of our analysis, feedback of the experts, information from our peers, our own experienced and knowledge we gained during the lectures of the rebuilding education course,  we made a redesign that forms a basic structure for all the bachelor courses of medicine.

For each bachelor year, we made a different model. Table 2, 3 and 4 represent the models of year 1, 2 and 3 respectively.

Pass or fail tests

As shown in the tables, we chose to add two pass or fail tests for the first year students, one pass or fail test for the second year and leave out these tests for the third year students. First year students will need some more guidance in spreading their learning strategies, as they were used to making multiple small tests about specific subjects during secondary education. During the bachelor period, students will get used to starting earlier with studying and will get more intrinsically motivated to do so, so we reduced the amount of test moment each year. Furthermore, because the pass or fail test already test the students on their knowledge about the facts, the amount of “fact-questions” in the final exam can be reduced from 50% to 30%. We reduced the amount of test moments over the course of the bachelor, while not increasing the amount of “fact-questions” in the final exam again, because the focus of the final exams also slightly chances over the course of the bachelor to questions related to clinical thinking instead of the facts.

We chose to make to tests pass or fail tests instead of a test that is being marked, because pass or fail tests cause significantly less stress. However, this is on the condition that the required study material is very clear for the students, so that they don’t need to stress about what they should learn. Therefore, for every course, there should be a clear list of all the topics students need to learn. For movement and anatomy this means that all the anatomical structures discussed in week 1 (upper extremity) and all the structures discussed in week 2 (lower extremity) need to be placed on separate lists. The test will consist of 15 multiple-choice questions, and ten questions need to be answered correctly to receive a pass. Of course, like every other exam, the possibility exists to retake the test when failed the first time. The retake of both the first and second test will take place on wednesday in the fourth week, but for reasons of clarity we did not display this in the tables. If students fail for the second time, they will be able to retake the tests at the end of the semester in the same period of the retakes of the final exams.

We realise it might not only be more work for the students, but also for the teachers who need to make a lot of new tests and questions. This is not our intention and also unnecessary. Therefore, the teachers of each course should create a database with a lot of possible questions that can be asked. For movement and anatomy this means that only a few images of the anatomical structures need to be put into the database as one image shows a lot of structures and therefore has a lot of possible questions. Of course in some courses the facts and data part does not only consist of anatomy, but also contains other subjects such as knowing adverse events of different types of antibiotics. For these courses it is a bit more time consuming to make the questions, but because they are saved in a database, the teachers only need to do it when this redesign gets implemented for the first time. Another advantage of the database is that specific software programs can be used that randomly selects questions from the database and creates the tests. This software is already used for the “ready knowledge” test that is already given twice a year, so the teachers are already familiar with this. Moreover, this program allows the test to be published on the central examination website to which all medical students have access to with their own unique account. This makes it possible to plan the pass or fail test in the first twenty minutes of the brainstorm session, instead of planning in an extra moment which also requires the availability of the examination hall.

Presentations

As seen in table 2, 3 and 4, we placed the extra presentation on thursday in the second week. In this way, students have almost two weeks to prepare themselves, they can already include a significant amount of study material discussed during the lectures in their presentation, while at the same time there is still more than enough time left to prepare for the final exam. The presentation will count for 30% of the final mark, so it will have significant influence on the final mark, but the main focus is still on the final exam, where both the knowledge of facts and clinical thinking part is tested. In addition, the presentations will be given in groups of six students, which means that the study groups that consists of 12 students need to be splitted in half. We have already seen that this is possible with regard to available classrooms and assessors, as in the 7th course of the second year a similar situation occurred.

Of course, in the current situation every student already needs to give one presentation per course. The intention is that students get the opportunity to improve their presentation skills, which is a very important skill for physicians as well as deepen their knowledge about the study material that is discussed during the lectures. However, the presentations need to be about the assignments of the brainstorm session, and often they only cover a very minor or specific part of the course. This causes students to see the preparation as useless, since at most, only one question on the final exam concerns their topic. So what we see, is that students don’t put much effort in the preparation and even copy slides from other students.

Nevertheless, presentations are very important and could really help the students in mastering the study material when they put enough effort in it. Therefore we propose this extra presentation for which the students get graded, which in turn obligates them to put effort in this.

We realise that by grading the students this only motivates them extrinsically to put effort in the preparation, so we also made some criteria for the possible content of the presentation. Every course, there are some clinical conditions or diseases that form the main focus of that particular course. These diseases are discussed during the lecture and described in the required literature, but often also other diseases and clinical conditions are discussed, which sometimes makes it hard for students to select the most important diseases. Therefore, the teachers of the course need to select the 6 most relevant clinical conditions or diseases. The students then get the opportunity to choose the disease or clinical condition they find most interesting and form that as the basis for their presentation. In this way, students will also be intrinsically motivated, because they can deepen their knowledge in the subject they like most, but in the same time will also learn about the other diseases, as they need to listen to the presentation of their peers.

Our analysis also showed that students resisted the idea of an extra presentation because the grading system will be unfair and the topics of the presentations feel useless with regard to the preparation for the final exam. To tackle both problems we made a guidelines for the content that needs to be in the presentations (table 5) for the assessment criteria for the teachers (table 6). The guidelines for the content include all important aspects that students also need to learn for the final exam and is adjusted to the focus of each bachelor year. The assessment criteria are also adjusted for each bachelor year, and students are both assessed on their presentation skills and the content of their presentation and both aspects determine the mark for 50%.

As seen in the tables, first years need to focus mostly on the pathophysiological background of diseases, second year students mostly on clinical thinking and third year students mostly on treatment options. This is in line with the focus of the bachelor years, and also ensures that during the course of the bachelor, students learn to investigate and present different important aspects of diseases.

Quality of study groups

The first part of our redesign mainly focussed on extrinsic motivation of the students, although we do think that the criteria and the content of the presentation also motivates the students intrinsically, since learning about diseases is often seen as the “fun” part of medicine. However, to further increase the internal motivation of students, we will redesign the study groups, as they form an important aspect of the structure of the bachelor courses and are a huge frustration points under medical students.

First of all, we propose that only teachers with a medical background should be hired to lead those meetings. This can be either physicians, physician-assistants or medical students. We realise physician and physician-assistants are scarce, so the addition of medical students should fill the gap. Further advantages of medical students as teachers are discussed in the justification section of the didactic perspective.

Secondly, we propose that the study material that is necessary to properly prepare for the assignments of the brainstorm should be posted online. Right now it is unclear how students can prepare themselves, except for attending the lectures. However, the lectures also cover only about half of the assignments, so a real discussion about the answers is often not possible. Advantages of posting the study material online is also further discussed in the justification section of the didactic perspective.

Effect on stress levels of our redesign

The main consequence of our redesign is that last-minute learning behaviour of students will be prevented by the addition of extra test and assessment moments, which also leads to reduced stress levels in the last week of the courses. In addition, the improved quality of the study group meetings and the extra presentation, makes that students have learnt more efficiently during the course, and therefore need to revise significantly less study material to prepare for the final exam. Moreover, because the final exam now only determines the grade for 70% the focus is less emphasized on this moment, which also reduces the stress.

Figure 8 shows the current situation, where students procrastinate their work and only realise in the last week that there is still lots of work left. This is shown by the enormous increase of the slope of the graft near the end of week 3 and during week 4.

Figure 9 shows the situation right after implementation of our redesign. Here the pass or fail test and the extra presentation are new for the students, which causes some amount of stress, but by far not as much compared to the final exam in the current situation. However, there is already a decrease in the stress levels for the final exam, as there is less work left for the last week, and the final exam is not the only determinant for the final grade anymore.

Lastly, figure 10 shows the situation when the students are used to our redesign. The pass or fail tests won’t cause any stress anymore (or at least negligible little), and only the stress for the presentation and final exam is left. However, the total amount of stress is significantly reduced compared to the current situation.

Justification

Minor subject: Translational Science in Medicine

As mentioned before, the courses of the first two bachelor years and the second half of the third bachelor year all have the same structure, with lectures, practicals, study groups and one central final exam that consists of multiple-choice questions. The lectures are not obligatory, but the practicals and study groups are. The study group meetings are meant to stimulate students to actively process the study material that is discussed during the lectures, while the practicals are meant to show different perspectives on the study material of the lectures and dive deeper into it. In addition, some practicals are specifically meant to improve practical skills such as communication and physical examination, but those often stand apart from the course subject.

This structure however, is only efficient and effective when students actually go to the lectures (and pay attention) and prepare themselves for the lectures practicals by reading the required literature. Medicine is a study with a lot of contact hours, which means that there is little time left to prepare for everything, so most students don’t prepare anything for lectures or practicals and some even don’t visit the lectures. This affects the quality of the brainstorm session significantly, because most students don’t have useful input and there is no real discussion about the cases (which is the goal of this meeting).

However, the first six months of the third year consist of the minor. This is a period during the bachelor where students can freely choose the subjects they are most interested in and where the opportunity exists to study abroad. The medical department of the VU organizes about ten different minors which all start with a common first course of four weeks called “translational sciences in medicine”. The course is quite similar to regular medicine courses, but the structure differs at certain important aspects.

First of all, the final mark of the course is not entirely dependent on one big final exam, but also exists of three exercises that are graded and together count for 30% of the final mark. Secondly, the first study group meeting was not a brainstorm session anymore, but it was a moment where the tutor shortly repeated and explained key aspects of the lectures and helped the students with the first draft of their exercises. During the second study group meeting, everyone had to give a presentation of the exercises or the answers of the exercises were discussed. Finally, there were no practicals during this course, but that is only because the subject did not really allow it.

Although beforehand most of the students did not like the extra work for the assignments that were now graded, afterwards many felt that it worked surprisingly well in reducing stress levels in the last week of the course. The subject of the course was extremely boring and the required literature was unclear, but because every week the students were obliged to put effort in exercises that were well connected to the lectures, the work that was left for the final exam was substantially reduced. Furthermore, the exercises helped to improve skills that are important are important for the student’s later careers as physicians. Students had to give a presentation (that was graded) and hold a PRO CON debate (which stimulated students to critically evaluate scientific articles).

Although the exercises were useful and stimulating the students to start early with applying the study material, we think a key element was that the subjects were part of the final mark of the course. During the first two years there have been some courses where students had to hand in an exercise, but those were never part of the mark but only had to be handed in. This resulted in sloppy works with no real effort, so students probably did not learn everything that they could have learned had to put more effort in it.

So to conclude, the extra exercises helped the students to improve skills that are important for their later career as physicians, and it helped students to start early with studying all the material which reduced the stress in the last view days before the final exam. The deadlines for the assignments of course lead to some amount of stress, but this was significantly less compared to stress for an exam, and the average stress over the four weeks also seemed to be less. It is important to reduce extreme stressful periods, because high cortisol levels and binge learning with sugar and caffeine drinks are bad for the student’s health and also reduce the efficacy of the learning process. Therefore, we reduce the overall experienced stress during a course by adding extra test moments and dividing the final mark in two parts, one presentation and one final exam. This makes the courses both more efficient and more effective. More efficient because students will better be able to actively participate in the brainstorm sessions, and more effective because students will remember more of the content of the course, because they started earlier with studying all the material.

Literature

Neuroscientific perspective

Our brain is often compared with a computer, there is an integrative system through which all information comes and goes. In reality, it turns out people easily forget facts, but we never forget our fears. When comparing this to computers, there is a huge difference as computers remember everything. To understand this principle it is important to understand a bit of how the brain works and how certain information is stored. Facts are stored by studying and they need to be repeated regularly. In contrary, fears are saved in a part of the brain called the amygdala. This structure has been important in our evolution and makes sure we don’t have to re-experience a certain fear to remember that we are scared of it.

Education cannot simply be seen as learning and putting information in our neural structure of the brain. There are a lot of influences that need to be taken into account when we say something about our educational system. This also implicates the constraints created by influences on the information uptake of our brain. Examples of these constraints are the situation at home, financial circumstances, emotional health, stress and so much more. These are most factors the educational system cannot influence.

However, the brain learns best from doing and predicting a certain outcome, it is not a passive sponge. When thinking of studying strategies of students, we can say summarizing might be interesting only when you try to think what this information means in other contexts and how to apply certain information. In other words, underlining, highlighting, reading, makes no difference as repeating information is not processing it and the information won’t be really stored. Reconstructing or retrieval practice works a lot better, the brain then actively processes the facts. This means that practicals and study groups become more important than the hours spent reading a book. Both the practicals and the study groups in medicine are meant to actively use the new information. For study groups  it is important that they will become more effective, as they have a lot more potential than the two hours of “sitting and waiting” it is now for most students. To achieve this study group tutors should be qualified, so the students become more intrinsically motivated to really participate. If this doesn’t happen, the use it or lose it principle will come around and students will forget the factual information they studied so hard for.

If we take a look at the assessments in the current medicine curriculum, only one at the end of a course and some overall tests every semester, there seems to be space for improvement. By creating more assessments during the course, the information is retrieved more often and the study materials are divided into smaller parts. This will make it easier for students to think more actively about the studied subjects and try other learning methods than reading the information. It also allows more apply-focused studying, which is an important aspect of medicine as that is how the information will be used in the longer term. Also, by adding an assessment in presentation format, a student will reconstruct and apply the studied materials after going through it thoroughly, more than they do now.

Philosophical perspective

When is education really educational? Richard Peters discusses this and he states that education must be intrinsically worthwhile. Moreover, the learner has to be intrinsically motivated to learn. This can be obtained in two ways. The first one is obvious: the value of reason. This means that students can see the point of what is taught to them. They understand the value of the knowledge they must gain and therefore, they are intrinsically motivated to learn. However, there is another thing that is important here: the absence of boredom. You can totally see the point of learning mathematics in order to graduate high school, but if you’re bored for six years listening to a teacher that talks about it, you won’t be intrinsically motivated.

This is an interesting point, because we see this in the medicine bachelor too. Almost everyone is determined to be a doctor. We all went through a strict selection in order to get in, so people are serious about it. We are also excited about the things we learn: otherwise, we would not have chosen to study medicine. Does this mean our education is intrinsically worthwhile? We think that is too bluntly. Sure, if you look at the whole picture, this may be true. But our education is more complex. If you look more specifically, you will see boredom everyday. In order to know how that affects the intrinsic worth of our education, it is important that we distinguish two types of boredom.

The first type is boredom as a low concentration-level. After a three one-hour lectures, you can expect people scrolling through their Facebook timeline during the fourth. This is an inevitable kind of boredom and I think that everyone experiences this every once in a while. You can be extremely intrinsically motivated and still be bored after an afternoon full of lectures. We see this in the medicine bachelor, but anyone will see this, no matter what bachelor they observe. The fact that this is common, does not mean it should not be changed. The last 20 minutes of a lecture can be as important as the first 2 hours, so it is important to keep the students interested. Maybe organizing shorter lectures or other ways of teaching to keep it more vividly could be a solution.

The second type is boredom as a constant state of mind because of lack of interest. For example, a practical about insurance medicine. Hardly anybody is excited for that and everybody walks in thinking how soon he or she can get out. Again, this is something every bachelor student experiences. In a three-year bachelor curriculum there are dozens of topics and you cannot make sure that everybody likes all the topics. However, in the medicine bachelor, we noticed a structural lack of interest. This is during the studygroup. As explained before, during the brainstorm session there is little input and participation from the students and most students just wait for it to be over. By improving these sessions, we want to make students more excited and less bored during the brainstorm. This improvement will be described in the next perspective.

Let’s go back to Peter’s definition of intrinsically worthwhile education. The values of reason are adequate amongst medicine students; it is clear why we have to learn all our stuff and we see the point of learning, for example, a 200-item list of anatomy. It is the absence of boredom we struggle with. Although we are excited about most subject matters and the human body, we regularly find ourselves bored during lessons of brainstorm sessions. This is not so much due to the content of the education, but more to the education style. We feel that the structure of some classes has to be changed to keep students excited. In this way, students can be more intrinsically motivated. And then, our medical education will be intrinsically worthwhile.

Didactic perspective

Student engagement encompasses three aspects; behavioural engagement, cognitive engagement and emotional engagement. Behavioural engagement includes the students’ effort, persistence, participation and compliance with school structure. This is for example the extent to which students follow the lectures and prepare themselves for practicals or study group meetings. Cognitive engagement is focused on the student’s internal investment in the learning process. This is not just about doing the assignments (behavioural engagement), but more about putting effort in understanding and mastering the assignments. Students can for example work hard, but still struggle to pass tests, because they only put effort in doing the assignments, but not in understanding it. Finally, emotional engagement is described as students’ feelings of interest, happiness, anxiety and anger during school-related activities and objects (assignments, teachers, classrooms etc.). Emotional engagement is also about the students’ feelings of importance of school-related outcomes and the students’ affection for school and individuals within the school (peers and teachers). For good results in education, it is important that these three aspects are all well developed and present in students.

Justification of improved quality of study groups

In the current situation, the quality of the study group meetings is low due to the fact that students don’t prepare themselves for those meetings. This can be due to lack of time, but the most important reason is that you cannot really prepare yourself for those meetings, except for attending the lectures. However, even when students did attend and understand the lectures, it is often hard to discuss the questions because the ask things that are not yet discussed during the lectures or need to be acquired from books. Another factor that diminishes the quality of especially the brainstorm session is that many teachers don’t have a medical background, and therefore have no idea what the assignments are about, which makes them unable to explain difficult aspects.

With our redesign we will improve the quality of the study group meetings by improving all three aspects of student engagement; behavioural, cognitive and emotional.

To improve the behavioural engagement, we propose that the study material that compromises the content of the assignments needs to be specified and posted online. From our own experience and what we heard from our peers, is that the ambiguity about what you can prepare is the biggest factor that determines whether or not students try to prepare themselves for the meetings. By posting the required reading material online, the threshold to prepare for the meetings will be lower as students don’t need to guess what they should do, which leads to an increased number of students that come prepared to the brainstorm session. This in turn enables them to actively discuss the assignments which in turn improves the quality of the brainstorm session. Of course when the quality of the meetings improves, the students are able to learn more during those meetings, which also improves cognitive engagement (they can effectively put effort in understanding the study material during the meetings).

Furthermore, we propose that only teachers with a medical background should be hired for the study group meetings. Physicians and physician-assistants are often very busy, so there won’t be many people amongst them that are available, so we propose that also medical students from higher years should be allowed to lead the meetings. This already happens in the practicals, where students are allowed to lead them after a short introduction course of real physicians and specialists. Based on our own experience, we think that this is a very good solution. Older students know exactly what you need to learn and most of the time have more than enough knowledge to teach the students of lower years. Moreover, the experienced students have gone to the exact same process as the current students, so they know from their own experience what works and what does not work. This will improve all aspects of engagement, but especially emotional engagement. Research has already shown that a positive student-teacher relationship improves student engagement (1) and that teachers that are directly involved in school activities increase behavioural engagement (2, 3). Teachers that are liked best by students, are teachers that actively help steering the discussions and give additional information (also outside the scope of the assignments) and the teachers students can relate to. Older medical students know a lot and are often easy to relate to. This will improve the emotional engagement, because the students will like the teachers better and therefore probably the brainstorm session itself as well. This in turn will improve the cognitive and behavioural engagement, because students are more motivated to learn about and prepare for things they like, so they will put effort in preparing themselves and in understanding the preparation.

Justification of reduced last-minute learning behaviour

As mentioned before, right now there is only one final exam which determines the final mark of a course which leads to last minute learning behaviour of students and high stress levels in the last days before the exam. This is partly due to low behavioural and cognitive engagement of the students in the first three weeks of the course. Students might be present during lectures, practicals and study group meetings, but they don’t really prepare for it and (especially during certain practicals and study group meetings) put no effort in understanding the study material. As described above, we will improve the situation by increasing the quality of the study group meetings, but to further enhance behavioural and cognitive engagement we propose extra tests moments of the facts and data of the study material and an extra presentation that is graded and counts for 30% of the final mark. The facts and data part of the course, which is anatomy in case of the course movement and anatomy, is often the most boring part and the part that is procrastinated the most by students. The extra tests moments (two in the first bachelor year, and one in the second bachelor year) will of course oblique the students to start earlier, which could lead to higher stress levels. However, it does improve the behavioural engagement of students, because they start earlier with the preparation for the final exam. Furthermore, once students are used to the test moments it won’t  cause them too much stress anymore, but helps to decrease the stress levels in the last week. In addition, during the bachelor, students will see that starting early really helps them and probably be better able to plan their learnings. For this reason, we start with two test moments in the first year which decreases to only one test moment in the second year to no extra test moment in the third year.

The extra presentation, that will also be marked, will further increase behavioural engagement, but also increase cognitive engagement. Because the presentation determines the final mark of the course for a substantial part, there is a big extrinsic motivation factor for the students to put effort in this assignment (behavioural engagement). In addition because the subjects of the presentation will be about diseases approached from different perspectives (histology, physiology, anatomy etc.) students are stimulated to understand diseases from the all the important perspectives. And because it about a relevant subject that they probably like (otherwise they would not have studies medicine) it will increase the cognitive engagement, as students put effort in understanding the study material and do this form different important perspectives. Furthermore, the presentation covers topics that are also assessed during the final exam, so by preparing for this assignment students also already learn for their exam which will reduce the amount of work left for the last week, which in turn reduces the high stress levels.

Justification of the pass-or-fail tests

In order to reduce the stress level and last-minute learning behaviour of students, we introduced the pass-or-fail test. After the lecture we got during this course about intrinsic motivation and student engagement, forcing students to take extra tests did not feel scientifically approved. Nonetheless, it felt like the only option to make sure that students would start learning right away. That is why we searched the web to find scientific proof that extra, obligatory tests work. And we found it. Research shows that testing works better than repeated studying or any other learning strategy. Other studies proved that repeated testing is better than one single test. This really proves our point of changing the form of one final exam at the end of each course. This study also found that a combination of various kinds of testing and little quizzes were very effective, so this research really supports our redesign

Feedback experts

During the feedback session, we presented our problem statement the way it is presented in this paper too. High stress levels, last-minute learning behaviour and the inefficiency this leads to. Our solution at this point was: spreading the performance moments over the block in order to spread out the stress peak. The feedback we received was predominantly about the same point: more assessment moments only motivate students extrinsically rather than intrinsically. Moreover, the high peak moments experienced at the end of a course are just divided in three smaller stress-peaks, which might lead to chronic stress rather than acute high stress moments. So, our newly gained question was how to get intrinsic motivation, but at the same time prevent last minute learning behaviour without creating too much stress moments.

So to improve the intrinsic motivation of the students, we did not want to add extra study material, practicals or lectures to the course schedule, since the schedule of medical students is already quite full. Instead, we decided to redesign a part of our education that could be a lot more effective: the study group brainstorm sessions.

Lastly, we were also a bit concerned about the addition of extra test moments. The feedback of the experts was that it would indeed lead to resistance amongst students, but that eventually students will grow into it as they get used to it or just know know better. For example, in five years, students won’t have experienced a situation without these extra test moments so they are more likely to accept this. The current bachelor students are used to the format of one final exam each course and nothing more than that, but if we implement our redesign for the new freshmen, they will do it and in the long term, it might be preferred.

In conclusion, we had two main feedback points. The first was: improve intrinsic motivation, the second one was: change will always cause some resistance. However, eventually it will be considered as normal and probably more effective.

Conclusion

To summarize, our redesign tackles two major issues of the medical bachelor; last minute learning behaviour and high peak stress levels in the last week of the courses. Our redesign consists of three aspects that tackles those problems; an addition of pass or fail tests, an addition of a presentation that counts for 30% of the final mark and improvement of the quality of study group sessions. The combination of these three solutions increase the extrinsic and intrinsic motivation of students to start studying earlier, which reduces last-minute learning behaviour and therefore improves the storage of information in the long-term memory and reduces high peak stress levels in the last week of the courses.

References

Fredricks, J. A. (2014). Eight Myths of Student Disengagement: Creating Classrooms of Deep Learning. Los Angeles: Corwin.

Kelly, S., & Turner, J. (2009). Rethinking the effects of classroom activity structure on the engagement of low-achieving students. The Teachers College Record, 111, 1665–1692

Marks, H. M. (2000). Student engagement in instructional activity: Patterns in the elementary, middle, and high school years. American Educational Research Journal, 37, 153–184.

Thomas, M. S. C., Ansari, D., & Knowland, V. C. P. (2018). Annual Research Review: Educational neuroscience: progress and prospects. Journal of Child Psychology and Psychiatry, . https://doi.org/10.1111/jcpp.12973

Adesope, O. O., Trevisan, D. A. & Sundararajan, N. (2017). Rethinking the use of tests: A meta-analysis of practice testing. Review of Educational Research. 87, 659–701. doi:10.3102/0034654316689306

Bae, C. L., Therriault, D. J., & Redifer, J. L. (2018, online first). Investigating the testing effect: Retrieval practice as a characteristic of effective study strategies. Learning and Instruction. doi:10.1016/jlearninstruc.2017.12.008