The course Heelkunde (Surgery) is a course for the first year master students of the Medicine programme at the VU. Ergo, these students also form the target audience of our case study. Our project is to redesign the course, especially the anatomy part, to improve the students’ learning experiences such that their knowledge can be better transferred from theory to practical work. This gap is caused by the way the study material is presented. The pictures/drawings in the textbooks are not representable for what students will actually see during surgery. Students are not able to recognize the anatomical structures of patients.
Since the course does not include exams or different forms of assessments, it is vital that the knowledge is well transferred to the students. As a result, this redesign offers solutions to the aforementioned problem and presents a minimum viable product. This product is an algorithm called Anki and provides flashcards that generate a better learning experience for students. The discrepancy between theoretical and practical work can be diminished by means of this product, which is also scientifically supported. This report discusses the issues, redesign, analysis, and justification in more detail.
The process of learning is often viewed as a dichotomy that includes two separate bodies in which one body focuses on theoretical learning and the other body focuses on practical learning (Orland-Barak & Yinon, 2017). Throughout the history of education, and also our own student experiences at the VU, one of the biggest challenges has always been to find a right balance between these two. Medicine students are expected to possess sufficient knowledge about the human body in health and disease, but should also be capable of applying this theoretical knowledge into practice. This is certainly of utmost importance when talking about our case study that focuses on the surgical side of healthcare.
The biggest challenge in the course ‘Heelkunde’ is stimulating active learning. An article by Wrenn, et al. describes this as a learning environment for students in which instructional activities are given to students that make them think about what they are doing and why they are doing it (Wrenn, 2007). This environment is important to allow students to welcome new knowledge and should promote students’ interest in the subject and encourage their participation (Wrenn, 2007). It is therefore important that these Medicine students should be able to prepare for the practical part of this course with the help of digital interactive tools that give them the opportunity to reflect on their current knowledge and what they still need to learn. This while also getting a good impression of what really goes on in the surgery room from an anatomical perspective.
This redesign was developed in collaboration with the team of Dr. Suzanne van der Velde and Robbert Winkel, the stakeholders in this case study. As students who are responsible for coming up with ideas for this redesign, we were, first of all, very interested in the student’s perspective on this course. How do they view this 12 week course and how big is the discrepancy between the theoretical and practical knowledge? And what is the cause of the fact that students are finding it quite difficult to recognize anatomical structures when they have an actual patient in front of them?
Ergo, the first step consists of a self-made survey that was designed to be filled in by the students that are currently following this course to get a good insight into their opinions. Unfortunately, this questionnaire could not reach the target audience as it would decrease the likelihood of students to fill in the standard evaluation form that they receive at the end of every course by the Vrije Universiteit itself.
After consultation with the team of Suzanne van der Velde and Robbert Winkel, we discovered the current issue within the education in the Master of Medicine, specifically in the Heelkunde Coschap for the students in year 4.
The team indicated that the problem lies in the study material that is too 2D and detailed. The students are flooded with this information before going into the clinic. Oftentimes, students are also only able to study from the classic anatomical atlases, which adds to the problem of their knowledge being too 2D. At first, this might not seem like a huge problem. However, for some students studying anatomy is difficult this way, as an anatomical atlas differs quite a bit from the real life situation. When the surgeon asks a student about a certain blood vessel, the student is often unable to answer. Understandably, this can cause a lot of problems in the general course of the Coschap and additionally in the later education of the student.
Within our group, we have taken a look at the Canvas page and we think the issue the page is facing lies predominantly in the density of the information that is presented to the student. While all the information on the page is relevant, it is offered all at once, which makes the student feel demotivated to read and understand the large amount of knowledge visible.
This lack of motivation can lead to difficulties in finding an active learning environment. The Canvas page Heelkunde Proeftuin, which is the new Canvas page the team of Suzanne has been working on, focuses on the improvement of the active learning environment. As of right now, this environment has already been drastically improved with respect to the current page. The regular page lacks interaction as it simply provides a number of links and videos. Additionally, the Files tab is hidden, which makes it more difficult for students to find a specific file they need for revision or studying. Another point of improvement is the Discussions tab. In our own bachelor programmes, this tab was used frequently, which improved communication between teacher and student. This allowed for a more interactive environment as well. As the tab is already in use occasionally, our recommendation would be to broaden this use. Another point we want to touch upon is making use of a specific tab voor Zoom meetings, as the KTO part of the coschap does make use of occasional Zoom meetings.
The focus of the redesign is to create a minimal viable product (MVP), which is done via a tool called Anki. Anki is a free computer program to learn flash cards through spaced repetition and is very well-known among Medicine students. The program takes into account the extent to which the user knows something and how long it has been since the flashcard was shown through the algorithm. The purpose of this tool is to help the students remember and practice many of the knowledge they have to learn by heart like the locations and functions of organs, blood supply, nerves, etc. Currently, this knowledge is presented as lists in documents. However, this is not study-friendly as there is no interactive factor or things that make information stand out in order to help with remembering. Therefore, the idea to use flashcards would be useful for the students.
Anki offers the possibility to write a complete elaboration on the correct answer on the flashcard by means of figures and pictures in order to make the answer of the flashcard as clear and memorable as possible for the student. Students go through the flashcards according to an algorithm that adjusts for every student such that they are shown specific flashcards according to their previous performances and when they last studied the card. Anki has a flexible algorithm: the user can adjust some general parameters and for each card during each review the user has four options to rate a card fail – pass (hard, good, easy). Hard and easy modify all future scheduling of the card. If a student marks a card as “again”, the algorithm will show the card again in less than 10 mins, if they marked it as hard it shows it after 12.1 hours, “good” after 1 day, and “easy” after 4 days. If a student does not change the standard settings and always rate a card as good (not easy, not hard), Anki multiplies the prior interval by 2.5 (minutes, hours, days, etc.). This helps students optimally study and revise information they have already learned so they do not forget it.
Anki allows students to deal with thousands of small and short cards, therefore applying the minimum information principle. This principle states that simple questions formulated for active recall in learning bring much better memory outcomes than complex questions even though one complex question may be equivalent to a large number of simpler questions. With the help of a computer software that can provide the students with the study material, students can easily and quickly prepare for the real-life co-schap.
Another advantage is that Anki allows the student to review the flashcard from his or her smartphone. This allows the students to practice the flashcards even when they are, for example, waiting for the bus. Anki also has many other advantages such as audio and video fragments or images that can be added.
The flashcards can be implemented by the teachers or students, in which they could share the deck of cards with other students or teachers. At the most micro-level, the MVP can be made that only one student uses Anki’s flashcards. This can be used to compare their performance with another student who has similar grades and performance with other courses, and studied the same overall number of hours. The teachers can then learn which student performed better and hence if Anki helped the student learn better. For less bias, this experiment can be done at a larger scale with 10 or more students, or with all of the course and compare the overall average performance of all students with that of students from the year before in which Anki wasn’t used. See appendix A for examples of flashcards from Complete Anatomy with additional annotations that can be used to clarify the answer to the anatomy questions.
For the justification part of our report, we have chosen to justify our redesign through three different perspectives: Teacher, student and surgeons.
The medical field is extremely broad and especially teaching students the anatomical structures is quite a challenge for teachers since the actual learning material is plain. Teachers have a hard time trying to find the most efficient and student friendly way to present the ‘item lijst’, which is the list of anatomical structures students should know when they enter their residency. Study has shown that spaced repetition, with use of Anki, is associated with superior performance on medical licensing examinations (Deng, Gluckstein & Larsen, 2015). This is due to the principle known as retrieval practice. It’s the act of recalling information from memory through questions and testing which makes the memory of the information, in this case the anatomical structures, stronger (Roediger & Karpicke, 2006). The use of Anki as an educational tool is supported by the theory of Ebbinghaus’s forgetting curve. The graph is a visual representation of how memory fades over time. His research concluded that the biggest drop of retention happens soon after learning the new study material. “Our ability to retain information plunges without reviewing” (Murre & Dros, 2015).
In addition, his research shows that the way study material is being presented, affects learning. Meaning, the long ´item lijst´ that does not have any color nor pictures, is not an efficient way to present the learning material. With the use of Anki, the ´item lijst´can be presented with pictures, videos, animations, colors and multiple variations of cards to present the flashcards (see Appendix, click here to access). Students will be more likely to remember the anatomical structures when it is presented clearly and in a well organized way.
The first review session should take place at the point where the forgetting curve has dropped significantly but has not reached 0% memory retention yet (the point where you start learning all over again). This means that you have to review every time the curve drops, but the forgetting curve is getting more shallow after each review session. Meaning, as time goes on, the time between each review session increases.
Spaced repetition by means of Anki has been proven to be an efficient method to the traditional method of immensely long, passive written item lists of anatomical structures. The research of Lambers, et al. provided the clinical relevance of using Anki even after medical school. There was a strong correlation between time spent and hence the number of flashcards reviewed using the Anki program and final examination scores. The research was done on twelve participants who were all orthopedic surgery residents. One of the conclusions of the research was that this method of learning could be applied to other areas of surgery and thus not only orthopedics. This shows how effective Anki is in teaching anatomical structures for surgical residents but is also a useful tool for surgeons who have already completed their training to keep their knowledge up to date through the spaced repetition algorithm.
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